Case 2
A 51-year-old man with a history of mild rheumatic mitral stenosis was
admitted to a secondary hospital due to a symptomatic third-degree
atrioventricular block with an escape rhythm of 40 bpm. It was decided
to implant a pacemaker; however, during the procedure the implanters
presented difficulties in advancing the guidewire. Venography was
performed, which evidenced a PLSVC with drainage in the CS, and absence
of RSVC. Our centre was contacted after these findings. Left axillary
venous access was performed, and due to our previous experience, a
Selectra 3D 65cm sheath (Biotronik, SE&Co) was used from the beginning
to facilitate the advancement of the lead to the RV. As in the previous
case, we accessed RA through the CS and performed a counter-clockwise
rotation to orient the sheath towards the TV and advance the guidewire
through it. The baseline ECG showed a left bundle branch block, so we
decided to pace the left bundle branch area. Using counter-clockwise
rotation, we supported the sheath against the interventricular septum
and inserted a Solia S60 electrode (Biotronik) in the usual way. To
check the optimal position and depth of the lead, left and right
anterior oblique projections were made after contrast injection. The RA
electrode was implanted without difficulty in the right appendage. The
values of impedance, threshold, and R-wave amplitude were verified
during the procedure. The ECG after implantation showed QRS narrowing up
to 140ms with a QR pattern in V1. During follow-up, the leads remained
stable, with no complications (Figures 2 and 3).