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J Clin Med. 2010; 3(2):39-43
PERSISTENCE OF LEFT SUPERIOR VENA
CAVA IN IMPLANTATION OF PERMANENT
ELECTROCARDIOSTIMULATOR
Sv. Iovev 1, Y. Dzhorgova1, B. Slavchev 1, M. Stoilova1, Ch. Panaiotov2
1
UNSHAT “St. Ekaterina” – Sofia
2
UMHAT “Aleksandrovska” - Sofia
Author for contacts: Sv. Yovev, MU – Sofia, Clinic of Cardiology, Department of Electrocardiostimulation and Electrocardiophysiology,
UNSHAT “St. Ekaterina”, 52A Pencho Slaveikov Blvd. – Sofia, Bulgaria; tel: +359 2 915 97 24, e-mail: [email protected]
Case Reports: Persistent left superior vena cava (PLSVC) occurs in 0.3 percent of the total population, demonstrated
in autopsy. This anatomical variant is usually discovered in patients during selective coronary angiography or procedures
for temporary or permanent electrocardiostimulation. We present two clinical cases, in which PLSVC is used as a route for the introduction of leads for electrocardiostimulation.
Case report №1
Persistent superior vena cava, as an additional
route for introducing third stimulating lead, in patient with cardiac resynchronization therapy system
A 58-year-old patient, diagnosed with “idiopathic dilated cardiomyopathy” (IDC), total heart failure (HF)
and left bundle branch block (LBBB). The condition
was discovered 7 years ago, when first symptoms of HF
appeared. An invasive diagnostics was performed in
2009 – selective coronary angiography (SCAG), which
excluded ischemic origin of the disease.
The patient has been with acceleration of symptoms
for one year, despite the optimal drug therapy with
beta-blockers, cardiac glycosides, diuretics, antiarrythmics and anticoagulants.
A course with Levosimendan administered twice
daily was carried out, resulting in slightly improved
global systolic function of left ventricle (LV) and temporary clinical effect.
The patient entered the clinic with total heart failure, orthopnoea, hepatomegaly, low cardiac output
condition. Catecholamine support was initiated with
Dopamine to stabilize hemodynamic.
Echocardiographic data (EchoCG) for diffuse hypokinesia - left ventricle ejection fraction (LVEF) - 10% with
telediastolic volume of the left ventricle (TDV-LV) - 86
mm, telesystolic volume of the left ventricle (TSV-LV) 60 mm. Mitral insufficiency (MI) – 1st degree.
By electrocardiography (ECG): sinus rhythm, LBB
and duration of QRS complex 160 ms.
The patient was evaluated as indicated for resynchronization therapy and a CRT system was implanted,
model - “Frontier - I - DDDR”. Access - left subclavian vein (v.subclavia sin.) and
vena cava superior. During the procedure, after the catheterization of
the coronary sinus (CS), an introducer was inserted
using electrophysiological catheter and an occlusive
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Fig 1 Retrograde venography through the coronary sinus, demonstrates
Fig 2 Anterograde venography – accessory vein, starting from the left
the persistent left superior vena cava (PLSVC) and a postero-lateral
subclavian vein and flowing into the coronary sinus with visualized leads
branch are visualized
of LV and RV
PLSVC - Persistent Left Superior Vena Cava
LV - Left Ventricle
retrograde venography was performed. It revealed the
presence of an additional large venous vessel – accessory vein, starting from the left subclavian vein and
flowing into the coronary sinus, with well defined single branch - postero lateral, suitable for implantation
of left ventricular lead (Fig. 1).
A Left Ventricular (LV) unipolar lead, model “Quick
site” (SJM), was introduced through the left subclavian
vein, superior vena cava, right atrium, coronary sinus
and the postero-lateral branch of the coronary sinus.
A Right Ventricular (RV) bipolar lead, model “IsoFlex
S 58cm” was introduced through left subclavian vein,
superior vena cava, right atrium, apex of right ventricle. Optimal parameters of stimulation and sensing
were programmed for both of the leads.
The impossible insertion of the Right Atrial (RA) lead
through the vena cava superior (smaller anatomical
caliber), required the conducting of an anterograde
venography (Fig.2).
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RV – Right Ventricle
A right atrial (RA) bipolar lead, model “Tendril 52”
was introduced through the left subclavian vein and
the additional venous way of the coronary sinus (PLSVC), into the right atrium (Fig 3, 4).
In the early post procedural period, there was significant progress in the general condition. On the second
post procedure day, the patient was mobilized and
able to climb two floors. On the third day, the tissue
Doppler imaging of the heart demonstrated improved
pump function of the left ventricle – measured IFLV
– 16%, with recovered intra-and inter- ventricular synchronicity.
At the post procedural computed tomography (CT)
scan with intravenous contrast, the three leads and
their routes of placement were visualized. The lead for
stimulating the RA was introduced through an anatomical variation of the venous system – persistent left
superior vena cava (PLSVC) Figure 5.
J Clin Med. 2010; 3(2):39-43
Case report №2
Persistent superior vena cava, as the only possible venous route for conducting a permanent
electrocardiostimulation
An 82-year-old patient diagnosed with: ischemic
heart disease (IHD); stable angina pectoris (SAP) – II-III
functional class (FC); hypertension disease – 3rd grade;
moderate mitral insufficiency; high degree tricuspid
insufficiency; severe pulmonary hypertension. chronic atrial fibrillation – tachy–brady syndrome; cardiac
pauses greater than 3 s. Ventricular extrasystoles IVA
class Lown. State after multiple presyncopal events.
Right bundle branch block (RBBB). Left anterior hemiblok (LAHB). Heart failure NYHA - FC III.
Fig 3 Retrograde introduction of right atrial stimulation lead through
PLSVC
The patient presented with shortness of breath and
fatigue after minimal physical exercise, blackouts and
fainting without loss of consciousness. The conducted
24 hours of Holter electrocardiography (ECG) demonstrated up to 35/min bradyarrhythmia and ventricular
extrasystoles IV A class Lown, cardiac pauses lasting
more than 3 seconds and ventricular tachyarrhythmia
with frequency up to 160/min. Class I indications for
implantation of permanent pace-maker (PM) – VVIR
type.
Fig 4 The three stimulating leads for left ventricle, right ventricle and right atrium, respectively
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Fig 5
Under local anesthesia and using right subclavian
vein access, we implanted permanent PM, model
“Verify”, type VVIR and Right Ventricular (RV) bipolar
lead “IsoFlex 58 cm. There were optimal parameters
for stimulating and sensing the right ventricular lead.
During the procedure, we discovered anomalous venous inflow in an accessory subclavian vein. The procedure itself went without complication.
into the right atrium via the coronary sinus, in approximately 92% of cases, there is no hemodynamic
expression and this is often combined with dilated
coronary sinus. In the rest of the cases, it flows into
the left atrium creating a right-left shunt. Anatomy of
systemic venous drainage is important for the procedures in anesthesia, electrocardiostimulation and cardiac surgery.
The post procedural contrast computed tomography
revealed (fig.6): The superior vena cava was situated
on the left, passing over the aortic arch, in front of the
left pulmonary artery, behind the auricle of the left
atrium, in front of the left pulmonary veins, behind
the left atrium and under it flowing into a dilated
coronary sinus near the inferior vena cava. Vena cordis
magna flowed into the superior vena cava at the level
of the left atrium.
In the presented case, the introduction of the leads,
stimulating the LV and RV through the superior vena
cava, turned to be obstructive to its caliber, thus preventing the use of this venous route for introduction
and placement of the third RA lead.
Discussion of case report №1
The persistent left superior vena cava is a congenital
anomaly (unsuccessful involution of the left cardinal
vein). Its incidence in the population is about 0.3%
– 0.5%. In 10% of the cases there is no right superior
vena cava.
When the persistent left superior vena cava flows
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Fig 6
The retrograde introduction of the RA lead through
PLSVC was the only possible route. Attempting to implant the left ventricular lead directly through PLSVC
in LV would create a lot of difficulties, because of the
sharp angle, which the PLSVC and the postero-lateral
branch of the coronary sinus form.
Discussion of case report №2
The persistent left superior vena cava is discovered
incidentally, most often in implantation of temporary
venous lead or in permanent electrocardiostimulation.
The access used for the implantation (v.subclavia sin.
J Clin Med. 2010; 3(2):39-43
or v.subclavia dex.) commonly determines the success
of the procedure. In the presented case, we accidentally ran into this anatomical variation of a persisting left
superior vena cava. When we used the route through
the superior vena cava, there were some difficulties
in introducing the lead in the right ventricle, due to
the presence of unusual angle that forms between
the coronary sinus and the right ventricle. The other
problem in this case, was the insufficient length of the
lead, because of the many additional curves in the described structures. The alternative access through left
v.subclavia would provide better and easier placement
of the lead in the right ventricle. Rarely these patients
require implantation of an epimyocardial lead.
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