Approaches for Successful Implantation of Cardiac Implantable Devices in Patients with Persistent Left Superior Vena Cava

Abstract

Persistent left superior vena cava (PLSVC) is the most common congenital thoracic venous anomaly, with 0.47% of patients undergoing pacemaker or cardiac implantable device placement found to have PLSVC. This review article describes challenges and interventions to successfully insert cardiac implantable electronic device leads into patients with PLSVC by providing multiple unique case examples.

Keywords: Cardiac implantable devices; coronary sinus; persistent left superior vena cava.

Figure 1:

Embryological development of the superior vena cava (SVC) and variations of persistent left SVC (PLSVC). The left upper panel shows common cardinal veins into sinus venosus. The right upper panel shows that the left common cardinal vein degenerates into the ligament of Marshall. The bottom panel shows a normal development where there is the presence of a normal right-sided SVC. The middle image shows the absence of a right-sided SVC and persistence of PLSVC. The right image shows the presence of PLSVC and a normal right-sided SVC. Abbreviations: BCV, brachiocephalic vein; LT, left; LV, left ventricle; RT, right; RV, right ventricle; SVC, superior vena cava. Republished with permission from DeFaria Yeh D, Bhatt A. Adult Congenital Heart Disease in Clinical Practice. New York, NY: Springer; 2018:143–150.

Figure 2:

A–E: Implantation of a dual-chamber cardiac defibrillator in a patient with persistent left superior vena cava via a left pre-pectoral approach. A, B: Custom-shaped curved stylet for right ventricle (cursive L) and right atrium (broad curve) lead implantation. Final image after implantation of dual-chamber defibrillator in the anteroposterior (B), right anterior oblique (C), and left anterior oblique (D) views showing the location of the atrial lead in the right atrial appendage and the right ventricular lead in the apical septal location.

Figure 3:

A–D: Implantation of a cardiac resynchronization therapy defibrillator in a patient with persistent left superior vena cava via a left pre-pectoral approach. (A) A venogram showing a lateral branch of the coronary sinus (CS), (B) use of the Worley™ vein selector to engage the CS branch, (C) advancing 2 wires into a CS branch in a “buddy wire” technique, and (D) successful advancement of CS lead into the lateral branch.

Figure 4:

A–C: Implantation of a cardiac resynchronization therapy defibrillator in a patient with persistent left superior vena cava (PLSVC) via a right pre-pectoral approach. (A) A coronary sinus (CS) venogram showing an anterolateral branch entering into the PLSVC, (B) the anterolateral branch was successfully engaged with a guidewire using an inner catheter, and (C) successful deployment of a CS lead into a high anterolateral branch. Abbreviations: CS, coronary sinus; L-SVC, left superior vena cava; LV, left ventricular; PLSVC, persistent left superior vena cava; RA, right atrial; RV, right ventricular; TVP, transvenous pacemaker.

Figure 5:

A–D: Implantation of a cardiac resynchronization therapy defibrillator (CRT-D) in a patient with persistent left superior vena cava (PLSVC) via a left pre-pectoral approach. (A) Inadvertent entry of the guidewire showing an unusual course suspicious for PLSVC, (B) venogram showing PLSVC, (C) successful implantation of the CRT-D via PLSVC in a left anterior oblique view, and (D) right anterior oblique view showing successful implantation of the CRT-D.