Pacemaker implant and single, persistent left superior vena cava

G. Pettinati, D. Melissano

Division of Cardiology, “F Ferrari” Hospital, Casarano (Italy)

3rd International Congress of the Mediterranean SOCIETY OF PACING  AND ELECTROPHISIOLOGY. (LISBONA 25 - 27 September 2003) Reprints from: Mediterranean Journal of Pacing and Electrophisyology. Volume 5, n.2, 2003

Left superior vena cava (LSVC) is a venous embryonic persistence directly communicating to the coronary sinus (CS). Which during the physical development become atrophic and transforms in the Marshal’s ligament. Persistence of LSVC is a relatively frequent alteration of the venous caval system, which occurs in the 0.3- 0,5% of the popula­tion, and is often associated to other cardiac alterations.

We describe a case in whom the pacemaker (PM) implantation was made very complex by occurrence of some alterations of the right superior caval system.

Case report: In a 68 years old male patient the PM implant indication was based un diagnosed sick sinus syndrome and symptomatic, cardioinhibitory carotid sinus syndrome, with recurrent syncopal spells associated to deep bust flexing and/or to rotational/flexural head movements. Both carotid sinus massage (gap of 4.5 s.) and APT test get positive results.

The surgical procedure for PM implantation was approached through puncture of lcft subclavian vein (LSV). During insertion of the guide wire (GW), it was observed that al the presternum level it was proceeding counter-laterally of inside the normal course. After several rotational and advancement attempts, it was seen that the GW progressed along the left margin of the cardiac shape. Then, an angiography of the LSV was performed. It evidenced a persistcnt LSVC communicating with the CS and then with the right atrium. Thereforc, the GW was pushed inside the vessel up to travel the CS and reach the right atrium. From here the GW was shaped in order to cross the tricus­pid valve and reach the right ventricle. Several attempts were performed without reaching any successful result.

In consequence of this negative experience it was decided to approach the implantation by the countcr-latcral side. After puncturing the right subclavian vein (RSV) a second GW was introduced. but Its advancement was stopped at the entry of the right superior vena cava (RSVC). RSVS was forming a “cul-de-sac’, cunter-laterally traveling to reach the persistent LSVC. A second angiography performed in the RSV showed the absence of a RSVC and pres­ence of a venous duct joining the RSV and the LSVC. The right jugular vein was flowing directly inside the RSV. At that time any attempt to implant the PM by endocavitary approach was stopped.

In a second time, an echographic investigation was performed to assess the position of the abdominal organs and an angiography. through the femoral vein, was also executed to assess the position of the inferior vena cava. No anatomic anomalies were found during these investigations.

Assessing the circumstance that the patient was presenting a single, persistent LSVC and that any attempt to ap­proach the right ventricle trough the endovenous access would be unsuccessful, it was decided to perform the PM im­plantation using the epicardial lead approach.