Single-lead VDD pacemaker implantation via persistent left superior vena cava: an improved technique and a new modality

Persistent left superior vena cava (PLSVC), which occurs in approximately 0.5% of the general population, may complicate pacemaker implantation by making lead insertion into the right ventricle more difficult and increasing lead instability when the transvenous approach is attempted. We describe our experience with four PLSVC patients with pacemakers. We developed an open J-loop technique in which the stylet tip is directed toward the orifice of the tricuspid valve anteroinferiorly. The lead was implanted into the right ventricular apex without difficulty. Three of our patients had high-degree atrioventricular block and received VVI pacemakers with the new technique. One patient with complete atrioventricular block received a single-lead VDD pacemaker by means of the same technique, with the paired electrodes positioned in the lower right atrium. Excellent results were obtained on exercise tolerance testing, 24-hour Holter monitoring, and echocardiographically determined systolic and diastolic function. This improved technique can simplify pacemaker implantation in patients with PLSVC. The VDD device is a new way to maintain systolic and diastolic function and is an appropriate option in patients with high-degree atrioventricular block and PLSVC who require pacemaker implantation.