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Amikam, S., Lemer, J., and Riss, E. (1977). Thorax, 32,[777][778][779][780]. Permanent right ventricular pacing through an anomalous left superior vena cava. A persistent left superior vena cava can complicate the implantation of a transvenous pacemaker. In a patient who required a permanent pacemaker, this venous anomaly was discovered during the insertion of the electrode but it did not prevent long-term right ventricular pacing. This was achieved after the electrode had been manipulated through the coronary sinus and right atrium. A plan of management is proposed for dealing with this unexpected problem.The majority of permanent pacemakers implanted today are of the pervenous endocardial type. In most cases the endocardial electrode is introduced through the cephalic vein in the deltopectoral triangle. One of the problems that may be encountered when using the transvenous endocardial electrode is the presence of a persistent left superior vena cava, which drains directly into the coronary sinus. This problem usually occurs unexpectedly, and, from the few descriptions of the anomaly discovered during pacemaker implantation, it is evident that no definite method of management has been established to deal with such cases (Kukral, 1971;Rose et al., 1971;Garcia et al., 1972;Rubenfire et al., 1974).The purpose of this paper is to present an additional case of a persistent left superior vena cava (PLSVC) which was found during the introduction of a pervenous permanent endocardial electrode and to describe the manner in which we dealt with this problem. We also propose a plan of management to be applied when faced with PLSVC during the introduction of a transvenous electrode. Case reportA 61-year-old woman was diagnosed as suffering from sick-sinus syndrome five years before the present admission. She had episodes of rapid atrial fibrillation and supraventricular tachycardia which produced palpitation, chest pain, and dizziness.Apart from these episodes of tachydysrhythmia her heart rate was slow. In the few weeks before admission the frequency of the bouts of rapid atrial fibrillation increased and the attacks could be terminated only with the aid of anitidysrhythmic agents which produced persistent symptomatic sinus or nodal bradycardia. It was decided to treat the patient with a permanent endocardial pacemaker without the initial insertion of a temporary electrode.At operation a 58 cm length Medtronic bipolar electrode was introduced via the left cephalic vein into the left subclavian vein. Under fluoroscopic control it was found that the course taken by the electrode was through a persistent left superior vena cava draining into the coronary sinus.

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In a pilot study, 21 patients underwent transbronchial fine needle aspiration (TBFNA) using a 45 cm-22 gauge needle guided by means of a semi-rigid metal sleeve, which was introduced through a standard rigid bronchoscope. A total of 33 aspirations were performed from main carina (15), paratracheal (five), and lobar carinal (13) The accepted methods of obtaining biopsies from mediastinal and para-mediastinal tissues are based on mediastinoscopy,1 2 anterior mediastinotomy,3 thoracotomy and median sternotomy. All these methods involve surgical intervention with its associated risks and expense. In many cases the aim is basically to establish an accurate pathological diagnosis. A method which can provide a pathological diagnosis with lesser invasion is advantageous.Lately microscope diagnosis of pulmonary and mediastinal malignancies has been obtained by means of transthoracic fine needle aspiration.4 However, this method has been used only in those cases in which the lesion was radiologically demonstrated, and it does not provide the surgeon with the information on mediastinal and hilar lymph node pathology which he requires for the assessment of operability.Based on our diagnostic experience in pulmonary cytology and technical experience in bronchoscopy and transthoracic FNA, we have combined both in a procedure directed towards obtaining cellular material by means of fine needle aspiration through the bronchial or tracheal wall during diagnostic bronchoscopy.Wang et a15 reported a series of five patients in whom paratracheal masses were aspirated transtracheally using a rigid bronchoscope and an oesoAddress for reprint requests: