A CASE OF DUAL–SITE LEFT VENTRICULAR PACING PERFORMED VIA A PERSISTENT LEFT SUPERIOR VENA CAVA IN A PATIENT WITH COMPLETE ATRIO–VENTRICULAR BLOCK AND RIGHT SUPERIOR VENA CAVA OCCLUSION

Abstract

Abstract Patient A 64 year old male admitted for syncope. EKG presented 3rd degree AV block. Attempting to place temporary pacemaker was unsuccessful due to occlusion of the right femoral vein and the presence of a catheter for hemodialysis in the left femoral vein. He also has complete thrombosis of the right internal jugular vein, proximal superior vena cava and right femoral vein. He was referred to ICCU for monitoring, asymptomatic with no signs of congestion or hypoperfusion. Dopamine was started at 4 mcg/kg/min and then isoprenaline 0.06 mcg/kg/min. Initial work up Echocardiography showed depressed LV ejection fraction (LVEF 40%). Chest and abdomen angio–CT showed persistence of a superior left vena cava (PSLVC), which drained in the coronary sinus (CS). Right axillary and subclavian veins were occluded, and also right superior vena cava and right jugular vein. Left jugular, axillary and subclavian veins were pervious. Left femoral and right iliac–femoral veins showed significantly narrowing of the vessel lumen. Diagnosis and Management Our indication for this patient was CRT rather than RV pacing. The implant of a leadless AV pacemaker was also considered, but it was considered unfeasible due to limited access from the femoral veins. The presence of a PSLVC cava draining into CS was confirmed with angiography in the EP Lab. At the beginning of the procedure two episodes of asystole occurred. A first bipolar lead was rapidly placed in a postero–lateral branch of the CS, to obtain a stable temporary pacing. We then placed a quadripolar, active fixation, left ventricular pacing lead via the PSLVC into an antero–lateral branch of the CS. Finally, we placed a right atrium active fixation pacing lead in the right atrium again through the PSLVC. Vascular accesses were cephalic left vein and axillary vein. Acceptable sensing and pacing parameters were achieved. The bipolar LV lead was connected to the IS–1 RV port for sensing and the quadripolar lead was connected to the IS–4 LV port for pacing. Programming was DDDR 60–130 with active LV pacing only. Total procedural time was 180 minutes. No complications occurred. At discharge electric parameters were stable. Echocardiography showed an improvement in LVEF (45% vs 40%) and ECG showed atrio–ventricular LV pacing. Conclusion As far as we know this is the first reported case of a CRT delivered by two left ventricle pacing leads both placed via a PLSVC, with no need to place a pacing lead in the right ventricle.