Journal of Heart and Cardiology | Volume 4 | Issue 2 | 2019-12-21

Persistent Left Superior Vena Cava (LSVC) And Permanent Pacemaker Implantation; Series Of 4 Cases

Sudeb Mukherjee

Abstract

Persistent Left Superior Vena Cava (LSVC) not very uncommon finding in cardiovascular interventional procedure. It often poses problem during Permanent Pacemaker Implantation (PPM) due to anatomic abnormal course of the venous system. Proper lead positioning becomes often difficult in such cases. Certain echocardiographic parameter and findings helps to diagnose this kind of abnormal findings beforehand. Expertise, proper use of skills and clinical knowledge is essential to perform such kind of procedure successfully when encountered. Here we have reported series of 4 such cases. First case is of a 66 year old male who required PPM implantation. During procedure it was found that he has LSVC and single chamber PPM implantation was done via LSVC.2 nd case describes Dual chamber PPM implantation via LSVC in a 52 year old male. 3 rd case demonstrates Septal pacing via LSVC in a patient with baseline LBBB (Left Bundle Brunch Block) and repeated syncope. In the 4 th case PPM implantation was done in a patient with dextrocardia via LSVC.

Keywords: Left Superior Vena Cava (LSVC), Permanent Pacemaker Implantation (PPM), Coronary Sinus (CS)

Full text

Persistent left superior vena cava (LSVC) present in ~0.5% of the general population, and up to 10% of those with established congenital heart disease [1] . The true incidence is however unknown as this anomaly exists without affecting the systemic venous return [2] . However, persistent LSVC has important implications in patients who undergo cardiac interventions such as placement of a transvenous pacemaker. This anomaly is also important in patients with associated congenital malformations where it may pose difficulty during catheterization and surgery. Persistent left superior vena cava results from failure of involution of left anterior and left common cardinal veins. In majority of the cases it drains into the RA by means of coronary sinus. In the remaining it drains into the LA via partially or completely unroofed coronary sinus. There is an increased likelihood of congenital heart disease if there is no right-sided superior vena cava or if the LSVC drains into the left atrium (LA) [3] . The clinical suspicion of LSVC is by observing greater distension and double a wave in the left jugular compared to the right jugular vein. Other clues to diagnosis are left paramediastinal venous crescent on chest x-ray, and an enlarged coronary sinus on echocardiography. Persistent LSVC is not the only cause of a dilated coronary sinus, however, with other etiologies including elevated right atrial pressure (most common), coronary arterio-venous fistula, partial anomalous pulmonary venous return, or an unroofed coronary sinus affording shunt flow between the left atrium and coronary sinus. . Transthoracic echocardiography reveals a dilated coronary sinus and diagnosis can be confirmed by use of saline contrast ( bubble study ) echocardiography. The following diagnostic criteria can be used with echocardiography: [1] the presence of a dilated coronary sinus on two-dimensional echocardiography in the absence of evidence of elevated right sided filling pressures; [2] enhancement of the dilated coronary sinus before the right atrium (RA) after contrast material infusion into a left arm vein; [3] normal transit of contrast with RA opacification before the coronary sinus with contrast injected from the right arm [4] . Pacemaker implantation has been reported in patients via persistent left superior vena cava [5] . In this article we present a series of cases in which pacemaker implantation was done in patients who were detected to have persistent left superior vena cava while undergoing pacemaker implantation. In all of these cases the implantation was done successfully without any complication. These cases also highlight the importance of careful clinical and echocardiographic examinations during preparative phase before taking these patients for surgery. Case Report 1 66 year old male admitted with recurrent episode of syncope. ECG revealed complete heart block. He was put on temporary pacemaker in emergency. After initial evaluation he was planned for permanent pacemaker implantation. The procedure was started after taking consent for the procedure. Puncture in to the left subclavian vein by percutaneous approach was done. When the guide wire was tried to introduce through the puncture needle it was initially felt with mild resistant. Terrumo wire was taken which passed through this puncture needle easily and reached to heart via left subclavian vein. At the fluoroscopy image the wire did not seem to be in the right side chambers of heart as normally it does. It looked like left sided superior vena cava (LSVC). 10 ml iso-osmolar dye was taken and pushed through left brachial vein to achieve venogram image. It was clearly visible now and confirmed the presence of left sided superior vena cava. 7F sheath was introduced through puncture needle, guidewire was removed and permanent lead was introduced. With the help of double curved loop the permanent lead for the right ventricle was screwed in good position with good threshold and impedance. The procedure was completed successfully (Figure 1 and 2). Procedure time was 31 minutes Figure1: Demonstrating LSVC and terrumo wire and Temporary pacemaker lead Figure 2: Showing Permanent screwed Lead through LSVC. Case Report 2 52 year old gentleman presented with repeated syncope with ECG evidence of advanced atrio ventricular block. He was planned for DDDR permanent pacemaker implantation. After initial percutaneous puncture through left subclavian vein the guidewire seems to be run along the left side of spine in AP view of fluoroscopy image. 10 ml is so smal dye was taken and injected into left brachial vein for venogram study. It was revealed that the gentleman actually has left superior venacanva. Terrumo wire was taken and passed into right atrium and into inferior vena cava. Right ventricular screwing lead was passed with the help of S shaped stylet and screwed in proper position with acceptable threshold and impedance. Right atrial ascrewing lead was screwed into right atrium with the help of single curved stylet. Procedure was completed successfully (Figure 3). Procedural time was 47 minutes. Figure 3: Showing DDDR pacemaker lead through LSVC. Case Report 3 42 year old lady admitted for pacemaker implantation for Left Bundle Branch Block and repeated syncope. She had no history of chest pain. Coronary Angiogram was done outside which revealed normal coronaries. Echocardiogram revealed normal Left ventricular ejection fraction. She was planned for Septal Pacing. After initial percutaneous puncture it was found that she has persistent left superior vena cava. Septal pacing was achieved without much difficulty and permanent pacing lead was actively fixed with satisfactory threshold (Figure 4 and 5). Procedure was successful. Procedure time was 17 minutes. Figure 4: Showing Septal pacing through LSVC Figure 5: ECG showing Septal pacing Case Report 4 29 year old gentleman admitted with recurrent syncope was found to have Complete Heart Block. He has dextrocardia. Echocardiogram revealed no structural abnormalities. He was planned for PPM implantation. After initial puncture it was found that He has persistent LSVC. Morphological Right ventricular Apical Pacing was achieved successfully (Figure 6). Procedural time was 1hour and 5 minutes. Figure 6: PPM lead in dextrocardia patient. Discussion Persistent LSVC always pose difficulty when approach from left side has been the choice during PPM implantation. In the first case (Figure 1 and 2) it was very much troublesome as the guidewire was not going beyond some point and it was felt with resistance. It may look like that subclavian vein has been punctured in a different place or there might be obstruction. The courseof the vein is different in presence of LSVC which is not understandable without venogram. After the venogram was done it was obvious that LSVC rather than obstruction is the cause. Therefore the guidewire can be pushed in that direction without worrying of perforation. Placement of the RV lead is also difficult due to bend and loop in the venous course. Implantation of pacemaker leads through a persistence of LSVC constitutes a challenging procedure as the lead enters the RV through the coronary sinus, making the maneuvering of pacing lead into the RV technically difficult [6] . Due to anatomical abnormality pacemaker lead has to go through loop via right atrium to right ventricle. There are reports of such implantation where long lead has been taken for such procedure [7] . There are reports of such procedure in children also [8] . Some authors preferred tined lead but most of them relied on active fixation lead [9,10,11] . Active fixation lead may lead to perforation [12] . But atrial lead pacing without active fixation technique is very challenging as lead displacement may occur. In this case series we have done this procedure with the normal length lead provided. Stylet need to be curved twice to reach RV apex. Some may prefer alfa helical loop or double curved S shaped loop. Placement of RA lead comparably easier than RV apical lead (as in the second case -Figure3). A single loop in the stylet may place the RA lead in desired position without much diificulty. Septal pacing has always been difficult in terms of proper positioning and needs to be confirmed by different fluoroscopic view. In the 3 rd case Septal pacing was done through LSVC and confirmed by several fluoroscopic view and ECG (Figure 4 and 5). PPM implantation in dextrocardia is always challenging. Position of the chambers of the heart needs to be evaluated in details before such procedure undertaken. In the 4 th case it took longer time to position the pacing lead in RV apical position. Overall the procedure time in each of the above the cases were longer due to difficult and unpredictable anatomy. It increases the radiation exposure to patients and operator. The complication related to puncture (pneumothorax, bleeding, perforation, arterial puncture) becomes higher due to anatomic difficult access in such cases. Many interventionalists preferred right sided approach in cases of LSVC. However right sided venous obstruction not uncommon and reports of successful implantation in such cases are there in medical literature [13,14] . Pre-operative evaluation thus becomes necessary in such cases. Presence of dilated coronary sinus (CS) may indicate presence of LSVC however several other conditions may results in dilated CS [15] . Preoperative venogram may delineate confirmly presence of LSVC. But mandatory venogram in all cases may expose the patient to dye related complications (allergy, renal dysfunction etc). Right sided venous access may alleviate problems of LSVC but most of the patients are right handed and left sided implantation is conventional. Therefore protocol based approach may be required to avoid such difficulties. Conclusion Persistent LSVC which is often encountered during PPM implantation poses difficulties due to anatomic abnormalities. Preoperative echocardiogram, high index of suspicion and pre-operativevenogram may confirm the presence of LSVC. Right sided approach may decrease the difficulties in negation of pacemaker lead in such cases. Increase fluoroscopic time and radiation exposure are another aspect of PPM implantation in patients with persistent LSVC. Lastly expertise approach might decrease overall complications in unpredictable cases. Fund Support There is no sponsor or fund support of any kind. Conflict of Interest There is no conflict of interest of any kind. Author s Contributions Sudeb Mukherjee Conception and design, Acquisition of data, Analysis of data. AbhinabAnand- Drafting the article. Sankar Chandra Mandal- Critical revision, redefining several aspects and final approval of article. Acknowledgements We acknowledge contribution from all 4 persons for giving us consent to report this case. References 1. Edwards, J.,DuShane, J. Thoracic venous anomalies. (1950) Arch Pathol 49: 514-537. Pubmed| Crossref| Others 2. Meadows, W. R., Sharp,J.T. Persistent left superior vena cava draining into the left atrium without arterial oxygen unsaturation. (1965) Am J Cardiol16:273 279. Pubmed | Crossref | Others 3. Cormier, M.G., Yedlicka, J. W., Gray, R.J., et al. Congenital anomalies of the superior vena cava: a CT study. (1989) SeminRoentgenol24(2): 77-83. Pubmed | Crossref | Others 4. Goyal, S.K., Punnam, S.R., Verma, G., et al. Persistent left superior vena cava: a case report and review of literature. (2008) Cardiovascular Ultrasound6: 50. Pubmed | Crossref | Others 5. Sundhu, M., Syed, M., Gul, S., et al. Pacemaker Placement in Persistent Left Superior Vena Cava. (2017) Cureus9(6): 131 1. Pubmed | Crossref | Others 6. Biffi, M., Boriani, G., Frabetti, L., et al. Left superior vena cava persistence in patients undergoing pacemaker or cardioverter-defibrillator implantation: A 10-year experience. (2001) Chest: 120:139-144. Pubmed | Crossref | Others 7. Dilaveris, P., Sideris, S., Stefanadis, C. Pacing difficulties due to persistent left superior vena cava. (2011) Europace13(1):2. Pubmed | Crossref | Others 8. Dalili, M., Alizadeh, A., Haghjoo, M. Successful implantation of transvenous pacing system via persistent left superior vena cava and coronary sinus in small children. (2010) Ind Pacing Electrophysiol J 10(12): 552-555. Pubmed | Crossref| Others 9. Zerbe, F., Bornakowowaski, J.,Sarnowaski, W. Pacemaker electrode implantation in patient with persistent left superior vena cava. (1992) Br Heart J 67(1): 65-66 Pubmed | Crossref | Others 10. D.H. Roberts., Belllamy, C.M., Ramsdale, D.R. Implantation of a dual chamber pacemaker in a patient with persistent left superior vena cava. (1992) Int J Cardiol 36: 242-243. Pubmed| Crossref| Others 11. Zardo, F., Nicolosi, G.L., Burelli,C., Dual chamber transvenous pacemaker implantation via anomalous left superior vena cava. (1986) Am Heart J 112(3): 621-622. Pubmed | Crossref | Others 12. Van Nooten, G., Verbeet, T., DeuvaertF.E. Atrial perforation by a screw-in electrode via a left superior vena cava. (1990) Am Heart J 119(6): 1439-1440. Pubmed | Crossref | Others 13. Girerd, N., Gressard, A., Berthezene, Y., et al. Persistent left superior vena cava with absent right superior vena cava: a difficult cardiac pacemaker implantation. (2009) Int J Cardiol 132(2) :117 119. Pubmed | Crossref | Others 14. umar, S., Moorthy, N., Kapoor, A., et al. A challenging dual chamber permanent pacemaker implantation in persistent left superior vena cava with absent right superior vena cava. (2012) J Cardiol Cases 5(2) :122 124. Pubmed | Crossref | Others 15. Mantini, E., Grondin, C., Lillehei, C., et al. Congenital anomalies involving the coronary sinus. (1966) Circulation 33(2): 317-322. Pubmed | Crossref| Others