A Novel Method of Placing Right Ventricular Leads in Patients With Persistent Left Superior Vena Cava Using a Conventional J Stylet

Abstract

BackgroundLocating pacemaker electrodes can become complicated by congenital abnormalities such as persistent left superior vena cava (LSVC).ObjectiveTo evaluate a technique for the implanting of ventricular electrode in patients with persistent LSVC.Materials and Methods The study was carried out from June 2001 to June 2010 involving all patients who were admitted to the Hospital Universitario Mayor, Instituto de Corazon de Bogota and Hospital Universitario Clinica San Rafael (Bogota-Colombia) for implanting pacemakers or cardiac defibrillators. LSVC was diagnosed by fluoroscopic observation (anterior-posterior view) of the course of the stylet. Four steps were followed: 1) Move the electrode with a straight stylet to the right atrium. 2) Change the straight stylet by a conventional J stylet and push the electrode to the lateral or anterolateral wall of the right atrium. 3) Remove the guide 3-5 cm and 4) Push the electrode which crosses the tricuspid valve into the right ventricle and finally deploy the active fixation mechanism.ResultsA total of 1198 patients were admitted for pacemaker or cardiac defibrillator implant during the 9-year study period, 1114 received a left subclavian venous approach. There were 573 males and 541 females. Persistent LSVC was found in five patients (0.45%) Fluoroscopy time for implanting the ventricular electrode ranged from 60 to 250 seconds, 40 to 92 minutes being taken to complete the whole procedure.ConclusionWe present a simple and rapid technique for electrode placement in patients with LSVC using usual J guide and active fixation electrodes with high success.

Persistent Left Superior Vena Cava with Absent Right Superior Vena Cava and Discrete Subaortic Stenosis Diagnosed in a Patient with Sick Sinus Syndrome: A Case Report and Brief Review of the Literature

“…In this case, the leads are advanced through the left SVC and the coronary sinus. Due to the acute angle between the ostium of the coronary sinus and the tricuspid valve, advancing the ventricular electrode through the tricuspid orifice is technically difficult and may be facilitated by forming a loop in the right atrium or by using a pre-shaped stylet [ 4 , 31 , 32 , 33 , 34 , 35 , 36 ]. Other pacing modalities such as leadless pacemaker or epicardial pacing systems might be an option whenever conventional therapy cannot be implemented [ 33 , 37 ].…”

Isolation of persistent left superior vena cava during atrial fibrillation ablation

“…In some rare cases, LVSC may persist and become a source of the AF episodes [2] , [3] . The diagnosis of LSVC is often made when a pacemaker is implanted or during insertion of CS catheter [4] . Misinterpretation of intracardiac electrograms due to persistent LSVC and the approaches that might be used during pulmonary vein isolation (PVI) are discussed in the present paper.…”

Pacemaker Implantation in a Patient with Paroxysmal Atrial Fibrillation and Persistent Left Superior Vena Cava with Absent Right Superior Vena Cava

“…Due to the anomalous left-sided SVC, the leads took a circuitous course via the PLSVC. An active fixation pacemaker lead was successfully placed at the right ventricular apex with acceptable parameters (bipolar: threshold 0.5 V/0.4 ms, impedance 500 Ω, R-wave amplitude 10 mv) by method of Mora G[ 1 ] [Figure 1b – 1d ]. The other active fixation pacemaker lead was positioned in the posterior wall of right atrium (RA).…”

“…Hand-shaped stylets and active fixation leads are also helpful in overcoming technical difficulties. Mora[ 1 ] introduced a method of ventricular placement with standard J stylet, which has a high success rate and is accompanied by less fluoroscope time and procedure than other series. The method described with four steps does not require a preformed stylet or use of special equipment, but rather uses a standard J stylet which is found in all pacemaker electrode package.…”