Case 1
We present the case of a 70-year-old man with a history of chronic
coronary syndrome, who was admitted due to recurrent syncope. The ECG
showed sinus rhythm with right bundle branch block. A cardiac magnetic
resonance imaging was requested, which reported a dilated cardiomyopathy
of ischemic origin with moderate ventricular dysfunction. As an
incidental finding, a PLSVC with agenesis of RSVC was observed, draining
into a dilated coronary sinus (CS). Therefore, an implantable
cardioverter-defibrillator (ICD) was indicated. Due to the absence of
RSVC, left axillary vein puncture was performed without incident.
Several attempts were made to introduce the ICD lead into the RV apex
through different modifications of the curve of the stylet; however, it
was repeatedly directed towards the RV outflow tract possibly due to
coil stiffness. Finally, we decided to use a Selectra 3D 65cm sheath
(Biotronik, SE&Co), commonly used for left bundle branch area pacing.
With a 0.375mm guidewire, we reached the right atrium (RA) through the
CS, and then we advanced the sheath through it. Once in RA, by
counter-clockwise rotation, we were able to orient the tip of the sheath
towards the tricuspid valve (TV) and cross into the RV without
difficulty. We subsequently removed the guidewire and advanced a Durata
7122-Q 65cm lead (Abbott Medical S.A.) up to the RV apex. After
confirming adequate detection and stimulation parameters, the sheath was
removed using the usual peel-away technique. The lead in RA was placed
in the right appendage, without requiring the use of a sheath. All
parameters remained stable during follow-up, with no complications
(Figure 1).