Successful cardiac synchronization therapy device upgrade using an active fixation quadripolar pacing lead in a patients with persistent left superior vena cava and absent right superior vena cava

概要

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Received: 9 May 2023    Revised: 1 July 2023    Accepted: 21 July 2023
DOI: 10.1002/joa3.12905

SPOTLIGHT

Successful cardiac synchronization therapy device upgrade
using an active fixation quadripolar pacing lead in a patients
with persistent left superior vena cava and absent right
superior vena cava
Shushi Nishiwaki MD | Satoshi Shizuta MD  | Munekazu Tanaka MD |
Hirohiko Kohjitani MD | Koh Ono MD
Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
Correspondence
Satoshi Shizuta, Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin-­Kawahara-­cho, Sakyo-­ku,
Kyoto 606-­8507, Japan.
Email: shizuta@kuhp.kyoto-u.ac.jp
Keywords: absent right superior vena cava, active fixation lead, cardiac resynchronization therapy, pacing-­induced cardiomyopathy, persistent left superior
vena cava

Persistent left superior vena cava (PLSVC) is a common congenital

The patient, a 70-­year-­old man, had visited our outpatient clinic

anomaly, with an incidence of 0.5%.1 Although PLSVC is usually as-

8 years prior, after experiencing dyspnea. A 12-­lead electrocardio-

ymptomatic, cardiac implantable electrical devices (CIEDs) should

gram (ECG) showed complete atrioventricular block with an escape

be implanted through the right superior vena cava from the right

rhythm of 43 bpm. Transthoracic echocardiography (TTE) showed

side because implantation through the PLSVC is technically difficult.

a left ventricular ejection fraction (LVEF) of 58%. We attempted

However, in patients with PLSVC concomitant with an absent right

to insert a temporary pacing lead from the right internal jugular

superior vena cava (ARSVC), CIEDs must be implanted through the

vein; however, the guidewire did not progress directly to the heart.

PLSVC. Several case reports of cardiac resynchronization therapy

Venography revealed PLSVC and ARSVC (Figure 1A). A temporary

(CRT) device implantation through the PLSVC have been published,

pacing lead was inserted into the right ventricle through the right

but left ventricular (LV) lead placement remains challenging in these

femoral vein. We implanted a dual-­chamber pacemaker (PM) (PM

patients. 2–­5 Here, we report a successful cardiac synchronization

generator: Reply DR; Sorin, atrial/ventricular lead: SelectSecure

therapy device upgrade using an active fixation quadripolar pacing

3830; Medtronic) from the left side using a deflectable guiding

lead in a patient with PLSVC and ARSVC.

sheath (SelectSite C304; Medtronic) (Figure 1B). Five years after PM

F I G U R E 1  (A) Venography revealed
PLSVC and ARSVC. (B) Chest x-­ray after
initial pacemaker implantation. (C) Twelve-­
lead ECG after pacemaker implantation.
QRS duration was 174 ms. ARSVC,
absent right superior vena cava; ECG,
electrocardiogram; PLSVC, persistent
vena cava.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of Japanese Heart Rhythm Society.
Journal of Arrhythmia. 2023;39:807–809. 

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www.journalofarrhythmia.org     807

NISHIWAKI et al.

F I G U R E 2  (A) Three-­dimensional
images of the PLSVC and the CS were
obtained using ECG-­gated contrast-­
enhanced computed tomography. (B)
Delay phase of coronary angiography.
Contrast jet flow clarified the junction
between the PLSVC and the CS. AP,
anterior posterior; CS, coronary sinus;
ECG, electrocardiogram; LAO, left anterior
oblique; PLSVC, persistent left superior
vena cava; RAO, right anterior oblique.

F I G U R E 3  (A) Contrast agent was
injected from the delivery catheter,
revealing the posterolateral vein. (B) A
0.014 inch wire was inserted into the
posterolateral vein. (C) An active fixation
quadripolar lead was advanced over the
wire into the posterolateral vein. RAO,
right anterior oblique.

implantation, he developed dyspnea; TTE revealed a deterioration

the posterolateral vein was very close to the junction between the

of LVEF to 33%. The ventricular pacing rate was 100%, with a wide

PLSVC and the CS. Therefore, we decided to target the posterolat-

QRS duration of 174 ms (Figure  1C). TTE revealed septal flash and

eral vein.

intraventricular dyssynchrony. As no other cause of LVEF deteriora-

The subclavian vein was punctured and a 0.035 inch hydrophilic

tion was identified, the patient was diagnosed with pacing-­induced

guidewire was advanced into the right atrium through the PLSVC. A

cardiomyopathy. After starting optimal medical therapy, the LVEF

9Fr introducer sheath (MediKit) was inserted into the PLSVC. A de-

slightly improved to 41% but did not normalize.

livery catheter with 130° curve (Attain Select II; Medtronic) was ad-

Eight years after PM implantation, he was admitted to our hos-

vanced to the junction between the PLSVC and the CS and contrast

pital for battery exchange. Since he still felt dyspnea while walking,

agent was injected, revealing the posterolateral vein (Figure 3A). A

we decided to perform a CRT device upgrade concurrent with the

0.014 inch wire (Attain Hybrid; Medtronic) was inserted into the

battery exchange. Preoperative three-­dimensional images of the

posterolateral vein (Figure  3B). An active fixation quadripolar lead

PLSVC and coronary sinus (CS) were obtained using ECG-­gated

(Attain Stability Quad; Medtronic) was advanced over the wire into

contrast-­enhanced computed tomography (CECT) (Figure  2A), and

the posterolateral vein (Figure  3C). Because the parameters at LV

the posterolateral and lateral veins were identified. The right ven-

2–­4 were acceptable (threshold: 1.5 V/0.4 ms; impedance: 608 Ω;

tricular lead had been placed in the right ventricular outflow tract,

no phrenic nerve stimulation at 8 V/0.4 ms), the quadripolar lead

opposite the posterolateral vein. Although the posterolateral vein

was fixed using a side helix. After removing the guiding cathe-

seemed to drain near the junction between the PLSVC and the CS,

ter and sheath, the existing right atrium/ventricular leads and the

the precise site was ambiguous. We performed coronary angiog-

new LV lead were connected to a CRT generator (Percepta Quad

raphy to confirm the relationship between the PLSVC and the CS

CRT-­P; Medtronic). The chest x-­ray on the following day showed

(Figure 2B). Contrast jet flow from the CS to the PLSVC clarified that

no dislodgement of the LV lead (Figure 4A). In the 12-­lead ECG, the

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F I G U R E 4  (A) Chest x-­ray after CRT
device upgrade. (B) Twelve-­lead ECG
after CRT device upgrade. Biventricular
pacing shortened QRS duration from 170
to 140 ms. CRT, cardiac resynchronization
therapy; ECG, electrocardiogram.

QRS duration of biventricular pacing narrowed from 170 to 140 ms

F U N D I N G I N FO R M AT I O N

(Figure 4B). One year after the upgrade, TTE revealed LVEF had im-

None.

proved to 63%, and dyspnea was relieved.
In patients with PLSVC and ARSVC, it is difficult to identify all
branches of the CS during the CRT device upgrade procedure be-

C O N F L I C T O F I N T E R E S T S TAT E M E N T
The authors declared that no competing interests exist.

cause retrograde venography using a balloon occlusion catheter is
usually impossible. Because 90% of the PLSVC drains into the CS,

PAT I E N T C O N S E N T S TAT E M E N T

the LV leads pass through in the following order: PLSVC, junction be-

The patient provided consent for publication.

tween PLSVC and CS, main body of the CS, and branch of the CS.1 In
a previous report, three-­dimensional CECT were used only to detect

ORCID

the CS branches.4 However, the difficulty of the procedure is likely

Satoshi Shizuta 

https://orcid.org/0000-0003-4587-9031

to depend more on the relationship between the junction site and
the CS branches than on the number or location of the CS branches.

REFERENCES

In our case, although the precise site of the PLSVC/CS junction re-

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of left superior vena cava. Clin Case Rep. 2020;8(9):1642–­6.
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mained ambiguous after three-­dimensional CECT, contrast jet flow
from the CS to the PLSVC in delayed coronary angiography images
clarified the junction position. Moreover, the posterolateral vein is
close to the junction site. Therefore, preoperative CECT and coronary angiography are both important for a success procedure.
Sufficient LV lead slack is usually left in the right atrium to prevent LV lead dislodgement during CRT device implantation. ...

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