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Implantation of a Cardiac Resynchronization System for Idiopathic Dilated Cardiomyopathy in a Patient with Persistent Left Superior Vena Cava Using an Experimental Lead for Left Ventricular Stimulation XAVIER LYON and LUKAS KAPPENBERGER From the Division of Cardiology, University Hospital, Lausanne, Switzerland LYON, X., ET AL.: Implantation of a Cardiac Resynchronization System for Idiopathic Dilated Car- diomyopathy in a Patient with Persistent Left Superior Vena Cava Using an Experimental Lead for Left Ventricular Stimulation. A persistent left superior vena cava (PLSVC) was discovered at the implantation of a cardiac resynchronization system in a woman with an idiopathic dilated cardiomyopathy. Standard leads were used to obtain right ventricular and right atrial (RA) stimulation according to a formerly de- scribed technique. The left ventricle was stimulated through the posterolateral vein of the heart by a novel lead design to be used over a guidewire for placement. Despite expected difficulties in this anatomic sit- uation, the research lead was positioned in 23 minutes. (PACE 2000; 23:1439-1441) persistent left superior vena cava, biventricular pacing, idiopathic dilated cardiomyopathy Introduction Persistent left superior vena cava (PLSVC) oc- curs in 0.1%-0.2% of the general population and up to 3%-10% when an associated cardiac mal- formation is present. It usually reaches the right atrium (RA) via a dilated coronary sinus (CS) and in 68% of cases an innominate vein bridges the two superior venae cavae.^ Implantation of pace- maker" and cardioverter defibrillator leads^ via a PLSVC bad been reported. Case Report A 55-year-old woman witb an idiopathic di- lated cardiomyopatby (IDCM) was enrolled in tbe Multisite Stimulation in Cardiomyopatby (MUS- TIC) study that was designed to evaluate the po- tential benefit of biventricular resyncbronization in beart failure. She was then admitted for the im- plantation of a device aiming to optimize tbe atri- oventricular delay by DDD pacing and to resyn- chronize both ventricles witb biventricular stimulation. A PLSVC draining to a dilated SC was incidentally discovered during the procedure (Fig. 1). Tbe RA lead (Medtronic 40fi8, Minneapolis, MN, USA) was passed down the PLSVC tben tbrough tbe coronary sinus (CS) to the RA ap- pendage. Tbe right ventricular (RV) lead Address for reprints: Xavier Lyon, M.D., Division of Cardiol- ogy. BH 16.309.1011 Lausanne-CHUV. Switzerland. Fax: +41- 21-314-00-13; e-maii; xlyonC</Jhola.hospvd.ch Received [uly 1, 1999; revised August 4. 1999; arxepted Octo- ber 7. 1999. (Medtronic 4023) was positioned at the RV apex using the same route, tbe tip going directly through the tricLispid opening. It was not possible to use this route to place tbe left ventricular (LV) stimu- lation lead in its target location (posterolateral vein of the beart) as this vessel formed an acute angle when catbeterizing tbe CS downstream. Therefore, we passed tbe lead from the left subclavian vein to the rigbt superior vena cava through an existing in- nominate vein that allowed us to proceed to the CS via the RA. We used a novel lead (Medtronic 10512) for tbis part of the procedure. First, a guid- ing catheter (Attain, Medtronic) is passed to the CS ostium, then a guidewire is advanced in the target vein. The electrode followed the guidewire by a side hole located at its tip (Fig. 2). A bemostatic valve witb a side arm is monnted over the guiding catheter and allows contrast injection throughout the procedure. The leads were connected to a biventricular resynchronization device (InSync 8040, Medtronic).' Tbe acute pacing parameters vv^ere suitable for (1) RA: pacing threshold 1.6 V (at 0.5 ms), signal amplitude 2.2 mV, and impedance 490 il (at 5 V and 0.5 ms), (2) RV: 1.1 V, 24 mV, and 638 H. and, (3) LV : 1 V. 14 mV, and 778 il, respectively. Fig- ure 3 sbows tbe final position of the leads. Discussion A PLSVC is usually not suspected prior to im- plant as not all tbe patients have chest x-ray find- ings than can evoke it and only 68% of PLSVC could be diagnosed successfully witb transtho- racic two-dimensional ecbocardiograpby.** PACE, Vol. 23 September 2000 1439
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Implantation of a Cardiac ResynchronizationSystem for Idiopathic Dilated Cardiomyopathyin a Patient with Persistent Left Superior VenaCava Using an Experimental Lead for LeftVentricular StimulationXAVIER LYON and LUKAS KAPPENBERGERFrom the Division of Cardiology, University Hospital, Lausanne, Switzerland
LYON, X., ET AL.: Implantation of a Cardiac Resynchronization System for Idiopathic Dilated Car-diomyopathy in a Patient with Persistent Left Superior Vena Cava Using an Experimental Lead for LeftVentricular Stimulation. A persistent left superior vena cava (PLSVC) was discovered at the implantationof a cardiac resynchronization system in a woman with an idiopathic dilated cardiomyopathy. Standardleads were used to obtain right ventricular and right atrial (RA) stimulation according to a formerly de-scribed technique. The left ventricle was stimulated through the posterolateral vein of the heart by a novellead design to be used over a guidewire for placement. Despite expected difficulties in this anatomic sit-uation, the research lead was positioned in 23 minutes. (PACE 2000; 23:1439-1441)
persistent left superior vena cava, biventricular pacing, idiopathic dilated cardiomyopathy
IntroductionPersistent left superior vena cava (PLSVC) oc-
curs in 0.1%-0.2% of the general population andup to 3%-10% when an associated cardiac mal-formation is present. It usually reaches the rightatrium (RA) via a dilated coronary sinus (CS) andin 68% of cases an innominate vein bridges thetwo superior venae cavae.^ Implantation of pace-maker" and cardioverter defibrillator leads^ via aPLSVC bad been reported.
Case ReportA 55-year-old woman witb an idiopathic di-
lated cardiomyopatby (IDCM) was enrolled in tbeMultisite Stimulation in Cardiomyopatby (MUS-TIC) study that was designed to evaluate the po-tential benefit of biventricular resyncbronizationin beart failure. She was then admitted for the im-plantation of a device aiming to optimize tbe atri-oventricular delay by DDD pacing and to resyn-chronize both ventricles witb biventricularstimulation. A PLSVC draining to a dilated SC wasincidentally discovered during the procedure (Fig.1). Tbe RA lead (Medtronic 40fi8, Minneapolis,MN, USA) was passed down the PLSVC tbentbrough tbe coronary sinus (CS) to the RA ap-pendage. Tbe right ventricular (RV) lead
Address for reprints: Xavier Lyon, M.D., Division of Cardiol-ogy. BH 16.309.1011 Lausanne-CHUV. Switzerland. Fax: +41-21-314-00-13; e-maii; xlyonC</Jhola.hospvd.ch
Received [uly 1, 1999; revised August 4. 1999; arxepted Octo-ber 7. 1999.
(Medtronic 4023) was positioned at the RV apexusing the same route, tbe tip going directly throughthe tricLispid opening. It was not possible to usethis route to place tbe left ventricular (LV) stimu-lation lead in its target location (posterolateral veinof the beart) as this vessel formed an acute anglewhen catbeterizing tbe CS downstream. Therefore,we passed tbe lead from the left subclavian vein tothe rigbt superior vena cava through an existing in-nominate vein that allowed us to proceed to the CSvia the RA. We used a novel lead (Medtronic10512) for tbis part of the procedure. First, a guid-ing catheter (Attain, Medtronic) is passed to the CSostium, then a guidewire is advanced in the targetvein. The electrode followed the guidewire by aside hole located at its tip (Fig. 2). A bemostaticvalve witb a side arm is monnted over the guidingcatheter and allows contrast injection throughoutthe procedure. The leads were connected to abiventricular resynchronization device (InSync8040, Medtronic).'
Tbe acute pacing parameters vv̂ ere suitable for(1) RA: pacing threshold 1.6 V (at 0.5 ms), signalamplitude 2.2 mV, and impedance 490 il (at 5 Vand 0.5 ms), (2) RV: 1.1 V, 24 mV, and 638 H. and,(3) LV : 1 V. 14 mV, and 778 il, respectively. Fig-ure 3 sbows tbe final position of the leads.
DiscussionA PLSVC is usually not suspected prior to im-
plant as not all tbe patients have chest x-ray find-ings than can evoke it and only 68% of PLSVCcould be diagnosed successfully witb transtho-racic two-dimensional ecbocardiograpby.**
PACE, Vol. 23 September 2000 1439
LYON, ET AL.
Figure 1. Venogram showing the persistent left superiorvena cava (PLSVC) draining into a dilated coronarysinus (CS). RA - right atrium.
The presence of a PLSVC can complicateproper positioning of an endocardial electrode.The RA lead is usually placed easily. However,tbe introduction of the lead into the RV is difficultbecause tbe tip of the lead tends to he deflectedaway from tbe tricuspid orifice. Several methodsbave been described for tbe RV lead placementlike curving the stylet into a pigtail,^ using a L-shaped lead,^ or forming a wide loop into the RAand then going down to the RV.̂ Sometimes, onlyan epicardial approach is feasible.
Tbe catheterization of tbe CS was shown to bebigbly successful and safe,^ but wben LV stimula-tion is needed, the final positioning of the elec-trode in the posterolateral vein of tbe beart is dif-ficult to acbieve. We bave experimented with tbisdevice (Medtronic 10512) to guide the tip of tbeelectrode more efficiently, and in tbis reportedcomplicated anatomic situation tbe final position-ing was obtained in an overall procedure time ofonly 23 minutes for LV stimulation.
Figure 2. (Panel A) Fluoroscopic view showing the guiding (arrows) positioned in the coronarysinus via the right atrium. (Panel R) Venogram showing the guidewire (white arrows) insertedthrough the guiding catheter (black arrows) and reaching the posterolateral vein of the heart.(Panel Cj Fluoroscopic view showing the tip of the electrode (black arrow) sliding over theguidewire (white arrows) aiming to the posterolateral vein of the heart. (Panel D) Final positioningof the electrode in the posterolateral vein of the heart.
1440 September 2000 PACE. Vol. 23
CARDIAC RESYNCHRONIZATION AND PERSISTENT LEFT SUPERIOR VENA CAVA
Figure 3. (Panel A) Anteroposterior thoracic x-ray showingthe three leads in place: right auricularlead (HAL. open arrows), right ventricular lead (HVL, black arrows), and coronary sinus lead (CSL,white arrows). (Panel B) Left lateral thoracic x-ray showing the three leads in place: right auricularlead(RAL, open arrows), right ventricular lead (RVL, black arrows), and coronary sinus lead (CSL.white arrows).
References1. Nsali EN, Moore GW. Hutchins GM. Patbogenesis of persistent left
superior vena cava with a coronary sinus connection. Pediatr Pathol1991; 11:261-269.
2. Dirix LY, Kersscbot IE, Fierens H, et al. Implantation of a dualcbambfir pacemaker in a patient with persistent left superior venacava. PACE 1988; ll::i43-345.
3. Mattke S, Markewitz A, Dorwartb U, et al. Defibrillator implanta-!iun in a patitml with a persistonl left superior vena cava. PAGE199S; 18;n7-120.
4. Zellcrs TM, Hagler D), JuLsrud PR. Accuracy of two-dimensional
echocardiograpby in diagnosing left superior vena rava. J Am SocEchocardiogr 1989; 2:132-138.Zerbo F. Bornakowski I, Sarnowski W. Pacemaker electrode im-plantation in patients with persistent left superior vena cava. BrHeart J 1992; 67:65-66.Hsiao HG, Kong GW, Wang JI. et al. Right ventricular electrode leadimpliinlation via a persistent left superior vena cava. An improvedtechnique. Angiology 1997; 48;919-923.Tbibault B. Dubuc M. Bourne G, ct al. Gathoterization of tbe coro-nary sinus, (letter) PAGE 1995; 18:1338-1339.
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