Challenges and pitfalls during CRT implantation in patients with persistent left superior vena cava

Feasibility of anchoring active fixation quadripolar lead to the main body of the dilated coronary sinus in a patient with persistent left superior vena cava: a case report

Background

Coronary sinus (CS) lead placement in persistent left superior vena cava (PLSVC) cases is challenging because of the poor backup force of the guiding catheter within the enlarged CS. Active fixation Quadripolar leads (Attain Stability™ Quad 4798, Medtronic) can expand choice to CS branches with limited access; however, no cases of anchoring to the main body of the CS have been published to date.

Case summary

We describe a case of cardiac resynchronization therapy pacemaker upgrade in a 79-year-old female who developed pacing-induced cardiomyopathy after pacemaker implantation via the right superior vena cava (SVC) for atrioventricular block eight years ago wherein PLSVC was revealed during the procedure. Retrograde giant CS angiography via SVC confirmed the lateral vein ostium. Attain Stability Quadripolar lead was selected; however, due to the tortuousness and stenosis of the target vein, the proximal electrodes could not advance into the target vein. Therefore, the side helix between the third and fourth electrodes was crimped to the anterior wall of the giant CS using the distal end curve of the subselection catheter and successfully screwed into the main body of the CS. At more than 6 months, left ventricular ejection fraction improved without lead dislodgement.

Discussion

Fixation of CS lead to the main body of the dilated CS was feasible by devising a guiding catheter and a subselection catheter. Nevertheless, the safety of active fixation lead retraction after long-term indwelling in CS is unknown and it should be carefully considered.

Management of Persistent Left Superior Vena Cava: Overcoming Lead and Vascular Complications With Transcatheter Pacing System Implantation

Isolated persistent left superior vena cava (PLSVC) is a rare congenital anomaly typically found incidentally due to its asymptomatic nature. However, it can present technical challenges for device implanters. We report a case involving a patient with PLSVC, for whom the implantation of a transcatheter pacing system proved to be the most effective long-term solution. Although this venous anomaly initially provided a safe pacing route, it eventually led to early complications. The patient, a 78-year-old Puerto Rican man with hypertension, diabetes mellitus, and complete atrioventricular block, experienced multiple complications with pacing devices. After a failed left-sided pacemaker implant, a right-sided single-chamber ventricular device was placed, but it led to right ventricular lead fractures and was eventually abandoned. A new pacing system implanted in the left chest lasted only a year. Venography revealed a patent PLSVC with a previously implanted device now obstructed by an occluded left brachiocephalic vein. After laser-assisted extraction, a dual-chamber device was successfully implanted through the PLSVC. Despite unremarkable physical and lab results, the patient later showed syncope and high lead impedances with fractures in both leads and total PLSVC occlusion. A transcatheter pacing system was chosen to address the complex anatomical issues and abandoned hardware. Atrial synchronized pacing was confirmed the morning after implantation, and the patient was safely discharged. Ensuring a stable ventricular rhythm is crucial for patients with complete heart block. When hemodynamic stability is compromised by recurrent lead fractures and rare anatomical variants, implanters must consider alternative solutions. In this case, a transcatheter system was selected to avoid further lead and pocket-related complications and mitigate the risks of additional laser-assisted extractions. At the end of the device's lifespan, a new device can be implanted without significant anatomical issues, and the epicardial route remains a viable option if necessary.