Cardiac Implantable Electronic Devices in Different Anatomical Types of Persistent Left Superior Vena Cava: Case Series and Brief Review of the Literature

Abstract

Persistent left superior vena cava (PLSVC) is the most common congenital malformation of the thoracic venous system, being present in 0.3% to 0.5% of the general population. In the majority of the cases, PLSVC is asymptomatic, but in certain patients, it can manifest through several symptoms, such as arrhythmias and cyanosis, especially when it is associated with complex cardiac pathologies. The clinical significance of this venous anomaly depends on the anatomical variant of the drainage site. In this article, we will present the experience of our clinic, with patients with PLSVC that were diagnosed intraprocedurally, during cardiac pacemaker (CP) or cardioverter defibrillator (ICD) implantation, highlighting the technical difficulties that this anomaly poses for cardiac device implantation. Out of 4000 patients who were admitted to our clinic for CP or ICD implantation, we encountered six cases of PLSVC (four reported in this article and two previously published) corresponding to different anatomical types of this congenital anomaly. In all of these situations, we had to adapt our technique to the patient's anatomy in order to avoid certain complications, the most serious being the improper placement of the right ventricle lead at the level of the coronary sinus.

Keywords: congenital anomaly; coronary sinus; defibrillator; pacemaker; persistent left superior vena cava.

Figure 1

Schummer’s classification of persistent left superior vena cava.

Figure 2

Advance of the ICD ventricular lead through persistent left superior vena cava, coronary sinus, right atrium, and finally, the right ventricle: (a) the guide wire (marked) descending to the left side of the spine; (b) the ventricular lead placed through the left SVC and coronary sinus into the RV.

Figure 3

Atrial and ventricular lead placement through innominate vein, right superior vena cava, right atrium, and ventricle: (a) the contrast injection in the left subclavian vein showing the presence of PLSVC and innominate vein, which ensures communication with right superior vena cava; (b) the final result after we placed the leads at the level of the right atrium (RAA) and right ventricular septum approaching the innominate vein and avoiding the coronary sinus.

Figure 4

Coronal section. The yellow arrows: the lead in the subclavian vein, persistent left superior vena cava, the innominate vein, and the right superior vena cava. The blue arrow: the right brachiocephalic vein.

Figure 5

Atrial and ventricular lead placement through PLSVC and coronary sinus: (a) the ventricular lead crossing a large coronary sinus and leaving behind a significant loop in the right atrium; (b) the final result with the leads at the level of the right atrium and right ventricular apex.

Figure 6

(a) The passage of the guide wire to the left side of the spine and then the venography confirming the presence of PLSVC, no communication with the right vena cava can be seen; (b) the defibrillation leads can be seen on the trajectory of the left superior vena cava (LSVC), through the coronary sinus (CS) into the right ventricular apex (RV)—red arrow. The atrial lead can be seen through the LSVC, coronary sinus, and right ventricle in the right atrial appendage (RA)—blue arrow.