Overcoming Difficulties Related with Persistent Left Superior
Vena Cava
Serkan Cay, MD; Ozcan Ozeke, MD; Firat Ozcan, MD; Serkan Topaloglu, MD;
Dursun Aras, MD
Department of Cardiology, Division of Arrhythmia and Electrophysiology,
University of Health
Sciences, Ankara City Hospital, Ankara, Turkey
Correspondence
Serkan Cay, MD
Department of Cardiology,
Division of Arrhythmia and Electrophysiology,
University of Health Sciences, Ankara City Hospital,
Bilkent, 06800 Cankaya, Ankara, Turkey
E-mail: cayserkan@yahoo.com
To the Editor,
We have read with great interest the article entitled ‘Cardiac
implantable electronic devices in patients with persistent left superior
vena cava - A single center experience’ by Ghazzal et
al1 in the latest issue of the journal. We would like
to thank the authors for their successful management of patients with
persistent left superior vena cava (PLSVC) who consecutively underwent
cardiac implantable electronic device implantation. As stated by the
authors, various tools and techniques can be used to overcome
difficulties when implanting a device through PLSVC. Lead implantation
in the right-heart chambers, particularly in the right ventricle, can be
challenging due to anatomic relationship between the ostium of the
coronary sinus and the right ventricular inflow. Shaping the stylet with
2 or more curves can help to direct the lead tip toward the tricuspid
annulus.2 Also, with the use of long sheaths such as
the standard coronary sinus sheath or steerable electrophysiology
sheath, one can cross the valve to achieve the right ventricular lead
implantation. Another difficulty is the optimal orientation of the
coronary sinus sheath and implantation of the left ventricular lead in
the targeted branch of the coronary sinus. Inferior approach from the
femoral vein can also be used to cannulate the targeted branch and to
implant the electrode. After optimal implantation with good electrical
parameters, the proximal end of the electrode can be moved from the
groin to the pectoral region using a snare or large bore catheters via
PLSVC. Previously described this inferior approach can also be used to
implant the right ventricular lead.3,4
Preprocedural imaging, not only for device implantations but also for
electrophysiologic procedures (Figure), is an important step for the
detection of PLSVC.5 During transthoracic
echocardiography, visualization of an enlarged coronary sinus can be
related with the presence of a PLSVC. Preprocedural diagnosis of PLSVC
can be achieved using contrast imaging. When agitated saline is injected
via the superficial veins of the left arm, bubbles appear first in the
coronary sinus before the right-heart chambers. For further confirmation
of PLSVC and imaging of other anatomic structures including the coronary
sinus and its branches, 3D imaging modalities such as computed
tomography angiography and magnetic resonance imaging can be
used.5
Last, previous medical interventional history such as bypass surgery can
prove the presence of a PLSVC before the procedure.
Keywords: coronary sinus; imaging; implantation; persistent
left superior vena cava