Clinical Imaging: Persistent Left Superior Vena Cava

In this new monthly section, authors will present case reports using mainly electrocardiographic and angiographic images to demonstrate pre- and post-procedure. Drs. Cohen and Lederman have provided a case on persistent left superior vena cava for the first installment this month. This patient is a 71-year-old man with a history of coronary artery disease, left ventricular ejection fraction of 30%, and recurrent syncope who is referred for an electrophysiology study. During the study, the patient had both inducible sustained ventricular tachycardia and severe His-Purkinje disease with an HV interval of 85 milliseconds. The patient was subsequently referred for an implantable cardioverter-defibrillator. The patient was prepped and draped in the usual sterile manner. A 2.5 ´ ´ incision was made two fingerbreadths below the left clavicle down to the prepectoral fascia. Subclavian venous access was obtained, and a guidewire and ventricular pacemaker lead was initially positioned along the left sternal border into the myocardium. Figure 1 shows this image. This figure demonstrates the presence of a persistent left superior vena cava. This is a rare finding during embryologic development, which can be seen in approximately 0.5% of implants. When the operator is confronted with this kind of access, it is often difficult to place the leads. Figure 2 shows the location of the ventricular lead in the myocardium down the persistent left superior vena cava into the coronary sinus vein. This was only elucidated after a coronary sinus venography was performed from the left subclavian vein. Figure 3 shows the persistent left superior vena cava, which accessed the coronary sinus. Figure 4 shows the fully injected coronary sinus venogram and branch (lower branch) which was accessed by the implantable cardioverter-defibrillator lead. Figure 5 demonstrates that with a guidewire, we were able to show access to regular circulation and the superior vena cava. By placing two angled guidewires and then a long sheath into the right atrium and right ventricle guide, both leads were secured (Figure 6). In conclusion, it is important to know about persistent left superior vena cava. In addition, it is important to be able to handle such a circumstance and achieve a successful implant without abandoning ship, so to speak. An alternative lead placement strategy would have been to utilize the coronary sinus vein (and perhaps its branches) in order to pace the left ventricle (through a lateral branch, for example) on the right ventricle/atrium (through the coronary sinus ostium and out into the right atrium and ventricle).¹ The latter approach may be useful for biventricular implants.²