International Journal of Cardiology 208 (2016) 26–27
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Implantation of a single coil ICD via persistent left superior vena cava Ozcan Ozeke ⁎, Ahmet Akdi, Serkan Cay, Firat Ozcan, Dursun Aras, Serkan Topaloglu Turkiye Yuksek Ihtisas Training and Research Hospital, Department of Cardiology, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 14 January 2016 Accepted 15 January 2016 Available online 18 January 2016 Keywords: Single-coil ICD Persistent left superior vena cava
Dear Editor; Persistent left superior vena cava (PLSVC) is a rare anatomic variation (0.07–0.13%) [1,2] that is typically asymptomatic and discovered incidentally during device implantation [3–12].Diagnosis can be difficult [13,14] and is often achieved incidentally since hemodynamics in these patients can be normal and clinical symptoms are mostly absent [15,16]. The number of detected cases has increased with the increasing number of pacemaker implantation. The characteristic finding on two-dimensional transthoracic echocardiography was a dilated coronary sinus (CS) with the diameter over 1 cm. The venous angiography was the gold standard for the diagnosis of PLSVC [10]. Important clinical implications include difficulties in central venous access or cardiac pacemaker placement as well as management consequences in cardiothoracic surgery [1] or cardiac ablation procedures [9,17,18]. A 65-year-old male patient with ischemic cardiomyopathy was referred to our clinic for primary prevention implantable cardiac defibrillator (ICD) implantation. The presence of a PLSVC leading to a dilated CS was incidentally found during advancement of the guide wire from the left subclavian vein to the superior vena cava (SVC) and was subsequently verified on venography (Video 1). The guidewire did not advance to the right SVC after routine puncture of the left axillary vein. Instead, an acute downward angulation was performed on the left side, parallel to the right-sided vena cava. A venogram was performed, and the diagnosis of PLSVC that descended into the coronary sinus (CS) was confirmed (Video 2). In first attempt, the ICD lead retrogradly was placed within CS (Video 3); therefore pacing showed atrial premature stimulation. Therefore, traversing the tricuspid valve and obtaining a stable position in the right ventricle required prolonged ⁎ Corresponding author at: Türkiye Yüksek İhtisas Hastanesi, Kardiyoloji Klinigi, Ankara, 06100, Turkey. E-mail address: [email protected] (O. Ozeke).
http://dx.doi.org/10.1016/j.ijcard.2016.01.198 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
manipulation. Finally, it could be implanted with retrograde loop by hand-shaped stylet (Videos 4 and 5). The appropriate sensing and pacing threshold confirmed that the ideal site via the single coil active lead had been reached, and the ICD was connected. Since the condition was more often diagnosed on the table and greatly lengthened the operating time, some precautions may reduce implantation time, failure, complications and X-ray exposure. The lead should be looped via shaped stylets due to the acute angle between the CS ostium and the tricuspid valve (Video 2). Hand-shaped stylets are often required. Alternatively, steerable stylets over the wire electrode, CS delivery systems or Worley's sheet may be used. Active fixation leads are the best choice because of the uncertainty of the lead position [5]. Finally, these patients must receive a follow-up examination because the incidence of lead dislodgement is higher than in normal patients. In conclusion, as the PLSVC was often an incidental discovery during a device implantation, therefore, the possibility of the PLSVC should be kept in mind when the guide wire took a left downward course during the device implantation. Although the implantation of the ventricular
Fig. 1. Fluoroscopy showing the implantation of single coil ICD lead via left persistent superior vena cava LPSVC: left persistent superior vena cava; CS: coronary sinus; RA, right atrium; RV, right ventricle.
O. Ozeke et al. / International Journal of Cardiology 208 (2016) 26–27
lead was technically difficult in patients with isolated PLSVC, there were several approaches to overcome it and successfully implant the ventricular lead in almost all these patients [10,19]. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2016.01.198.
[9]
[10]
Conflict of interest
[11]
The authors report no relationships that could be construed as a conflict of interest.
[12]
References [1] T. Heye, M. Wengenroth, A. Schipp, T. Johannes Dengler, L. Grenacher, K.G. Werner, Persistent left superior vena cava with absent right superior vena cava: morphological CT features and clinical implications, Int. J. Cardiol. 116 (2007) e103–e105. [2] T. Tak, E. Crouch, G.B. Drake, Persistent left superior vena cava: incidence, significance and clinical correlates, Int. J. Cardiol. 82 (2002) 91–93. [3] C.C. Fang, Y.T. Jao, S.C. Han, S.P. Wang, Persistent left superior vena cava: multi-slice CT images and report of a case, Int. J. Cardiol. 121 (2007) 112–114. [4] N. Girerd, A. Gressard, Y. Berthezene, P. Lantelme, Persistent left superior vena cava with absent right superior vena cava: a difficult cardiac pacemaker implantation, Int. J. Cardiol. 132 (2009) e117–e119. [5] M. Jiang, X.D. Shen, S.H. Zhou, J.L. Mao, B. He, Clinical consideration of cardiac pacemaker implantation through a persistent left superior vena cava with an absent right superior vena cava, Int. J. Cardiol. 159 (2012) e59–e60. [6] H.L. Ratliff, M. Yousufuddin, W.R. Lieving, B.E. Watson, A. Malas, G. Rosencrance, et al., Persistent left superior vena cava: case reports and clinical implications, Int. J. Cardiol. 113 (2006) 242–246. [7] N. Funabashi, M. Asano, I. Komuro, Giant coronary sinus diverticulum with persistent left superior vena cava demonstrated by multislice computed tomography, Int. J. Cardiol. 111 (2006) 468–469. [8] P. Korantzopoulos, M. Kolios, D. Nikas, J.A. Goudevenos, Implantable cardioverter defibrillator lead placement in the right ventricular outflow tract in a patient with
[13] [14]
[15]
[16]
[17]
[18]
[19]
27
Brugada syndrome and persistent left superior vena cava, Int. J. Cardiol. 181 (2015) 166–168. D.H. Roberts, C.M. Bellamy, D.R. Ramsdale, Implantation of a dual chamber pacemaker in a patient with persistent left superior vena cava, Int. J. Cardiol. 36 (1992) 242–243. Z. Cheng, H. Deng, K. Cheng, T. Chen, P. Gao, Q. Fang, Implantation of a pacemaker in a patient with persistent left superior vena cava and absence of right superior vena cava, Int. J. Cardiol. 168 (2013) e53–e54. P. Dilaveris, S. Sideris, K. Toutouzas, K. Gatzoulis, C. Stefanadis, Dual-chamber pacemaker implantation in a CoreValve recipient with a persistent left superior vena cava, Int. J. Cardiol. 166 (2013) 519–520. P.C. Lim, L. Baskaran, K.L. Ho, W.S. Teo, C.K. Ching, Coronary sinus ostial atresia and persistent left-sided superior vena cava: clinical significance and strategies for cardiac resynchronization therapy, Int. J. Angiol. 22 (2013) 199–202. P. Ardilouze, V. Bricot, C. Maurel, L. Christiaens, A rare case of left superior vena cava draining into left atrium demonstrated by MDCT, Int. J. Cardiol. 131 (2009) e65–e66. D. Aras, S. Cay, S. Topaloglu, F. Ozcan, O. Ozeke, A rare localization for nonpulmonary vein trigger of atrial fibrillation: persistent left superior vena cava, Int. J. Cardiol. 187 (2015) 235–236. Y. Guray, N.S. Yelgec, U. Guray, M.B. Yylmaz, A. Boyaci, S. Korkmaz, Left-sided or transposed inferior vena cava ascending as hemiazygos vein and draining into the coronary sinus via persistent left superior vena cava: case report, Int. J. Cardiol. 93 (2004) 293–295. Z. Yi, J.S. Sidhu, J. Cheng, A successful implantation of a dual-chambers cardioverter defibrillator for a patient with severe tortuous persistent left superior vena cava, Int. J. Cardiol. 133 (2009) e109–e110. K. Sakabe, N. Fukuda, K. Wakayama, T. Nada, H. Shinohara, Y. Tamura, Radiofrequency catheter ablation for atrioventricular nodal reentrant tachycardia in a patient with persistent left superior vena cava, Int. J. Cardiol. 95 (2004) 355–357. Y. Hirai, C.C. Chou, M.S. Wen, Catheter ablation of atrioventricular nodal reentrant tachycardia in a patient with complete situs inversus, atrial septal defect and "inverse" persistent left superior vena cava, Int. J. Cardiol. 115 (2007) e12–e14. M. Rivero-Ayerza, Y. van Belle, J. Mekel, L.J. Jordaens, Left ventricular lead implantation assisted by magnetic navigation in a patient with a persistent left superior vena cava, Int. J. Cardiol. 116 (2007) e15–e17.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Implantation of a single coil ICD via persistent left superior vena cava Ozcan Ozeke ⁎, Ahmet Akdi, Serkan Cay, Firat Ozcan, Dursun Aras, Serkan Topaloglu Turkiye Yuksek Ihtisas Training and Research Hospital, Department of Cardiology, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 14 January 2016 Accepted 15 January 2016 Available online 18 January 2016 Keywords: Single-coil ICD Persistent left superior vena cava
Dear Editor; Persistent left superior vena cava (PLSVC) is a rare anatomic variation (0.07–0.13%) [1,2] that is typically asymptomatic and discovered incidentally during device implantation [3–12].Diagnosis can be difficult [13,14] and is often achieved incidentally since hemodynamics in these patients can be normal and clinical symptoms are mostly absent [15,16]. The number of detected cases has increased with the increasing number of pacemaker implantation. The characteristic finding on two-dimensional transthoracic echocardiography was a dilated coronary sinus (CS) with the diameter over 1 cm. The venous angiography was the gold standard for the diagnosis of PLSVC [10]. Important clinical implications include difficulties in central venous access or cardiac pacemaker placement as well as management consequences in cardiothoracic surgery [1] or cardiac ablation procedures [9,17,18]. A 65-year-old male patient with ischemic cardiomyopathy was referred to our clinic for primary prevention implantable cardiac defibrillator (ICD) implantation. The presence of a PLSVC leading to a dilated CS was incidentally found during advancement of the guide wire from the left subclavian vein to the superior vena cava (SVC) and was subsequently verified on venography (Video 1). The guidewire did not advance to the right SVC after routine puncture of the left axillary vein. Instead, an acute downward angulation was performed on the left side, parallel to the right-sided vena cava. A venogram was performed, and the diagnosis of PLSVC that descended into the coronary sinus (CS) was confirmed (Video 2). In first attempt, the ICD lead retrogradly was placed within CS (Video 3); therefore pacing showed atrial premature stimulation. Therefore, traversing the tricuspid valve and obtaining a stable position in the right ventricle required prolonged ⁎ Corresponding author at: Türkiye Yüksek İhtisas Hastanesi, Kardiyoloji Klinigi, Ankara, 06100, Turkey. E-mail address: [email protected] (O. Ozeke).
http://dx.doi.org/10.1016/j.ijcard.2016.01.198 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
manipulation. Finally, it could be implanted with retrograde loop by hand-shaped stylet (Videos 4 and 5). The appropriate sensing and pacing threshold confirmed that the ideal site via the single coil active lead had been reached, and the ICD was connected. Since the condition was more often diagnosed on the table and greatly lengthened the operating time, some precautions may reduce implantation time, failure, complications and X-ray exposure. The lead should be looped via shaped stylets due to the acute angle between the CS ostium and the tricuspid valve (Video 2). Hand-shaped stylets are often required. Alternatively, steerable stylets over the wire electrode, CS delivery systems or Worley's sheet may be used. Active fixation leads are the best choice because of the uncertainty of the lead position [5]. Finally, these patients must receive a follow-up examination because the incidence of lead dislodgement is higher than in normal patients. In conclusion, as the PLSVC was often an incidental discovery during a device implantation, therefore, the possibility of the PLSVC should be kept in mind when the guide wire took a left downward course during the device implantation. Although the implantation of the ventricular
Fig. 1. Fluoroscopy showing the implantation of single coil ICD lead via left persistent superior vena cava LPSVC: left persistent superior vena cava; CS: coronary sinus; RA, right atrium; RV, right ventricle.
O. Ozeke et al. / International Journal of Cardiology 208 (2016) 26–27
lead was technically difficult in patients with isolated PLSVC, there were several approaches to overcome it and successfully implant the ventricular lead in almost all these patients [10,19]. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2016.01.198.
[9]
[10]
Conflict of interest
[11]
The authors report no relationships that could be construed as a conflict of interest.
[12]
References [1] T. Heye, M. Wengenroth, A. Schipp, T. Johannes Dengler, L. Grenacher, K.G. Werner, Persistent left superior vena cava with absent right superior vena cava: morphological CT features and clinical implications, Int. J. Cardiol. 116 (2007) e103–e105. [2] T. Tak, E. Crouch, G.B. Drake, Persistent left superior vena cava: incidence, significance and clinical correlates, Int. J. Cardiol. 82 (2002) 91–93. [3] C.C. Fang, Y.T. Jao, S.C. Han, S.P. Wang, Persistent left superior vena cava: multi-slice CT images and report of a case, Int. J. Cardiol. 121 (2007) 112–114. [4] N. Girerd, A. Gressard, Y. Berthezene, P. Lantelme, Persistent left superior vena cava with absent right superior vena cava: a difficult cardiac pacemaker implantation, Int. J. Cardiol. 132 (2009) e117–e119. [5] M. Jiang, X.D. Shen, S.H. Zhou, J.L. Mao, B. He, Clinical consideration of cardiac pacemaker implantation through a persistent left superior vena cava with an absent right superior vena cava, Int. J. Cardiol. 159 (2012) e59–e60. [6] H.L. Ratliff, M. Yousufuddin, W.R. Lieving, B.E. Watson, A. Malas, G. Rosencrance, et al., Persistent left superior vena cava: case reports and clinical implications, Int. J. Cardiol. 113 (2006) 242–246. [7] N. Funabashi, M. Asano, I. Komuro, Giant coronary sinus diverticulum with persistent left superior vena cava demonstrated by multislice computed tomography, Int. J. Cardiol. 111 (2006) 468–469. [8] P. Korantzopoulos, M. Kolios, D. Nikas, J.A. Goudevenos, Implantable cardioverter defibrillator lead placement in the right ventricular outflow tract in a patient with
[13] [14]
[15]
[16]
[17]
[18]
[19]
27
Brugada syndrome and persistent left superior vena cava, Int. J. Cardiol. 181 (2015) 166–168. D.H. Roberts, C.M. Bellamy, D.R. Ramsdale, Implantation of a dual chamber pacemaker in a patient with persistent left superior vena cava, Int. J. Cardiol. 36 (1992) 242–243. Z. Cheng, H. Deng, K. Cheng, T. Chen, P. Gao, Q. Fang, Implantation of a pacemaker in a patient with persistent left superior vena cava and absence of right superior vena cava, Int. J. Cardiol. 168 (2013) e53–e54. P. Dilaveris, S. Sideris, K. Toutouzas, K. Gatzoulis, C. Stefanadis, Dual-chamber pacemaker implantation in a CoreValve recipient with a persistent left superior vena cava, Int. J. Cardiol. 166 (2013) 519–520. P.C. Lim, L. Baskaran, K.L. Ho, W.S. Teo, C.K. Ching, Coronary sinus ostial atresia and persistent left-sided superior vena cava: clinical significance and strategies for cardiac resynchronization therapy, Int. J. Angiol. 22 (2013) 199–202. P. Ardilouze, V. Bricot, C. Maurel, L. Christiaens, A rare case of left superior vena cava draining into left atrium demonstrated by MDCT, Int. J. Cardiol. 131 (2009) e65–e66. D. Aras, S. Cay, S. Topaloglu, F. Ozcan, O. Ozeke, A rare localization for nonpulmonary vein trigger of atrial fibrillation: persistent left superior vena cava, Int. J. Cardiol. 187 (2015) 235–236. Y. Guray, N.S. Yelgec, U. Guray, M.B. Yylmaz, A. Boyaci, S. Korkmaz, Left-sided or transposed inferior vena cava ascending as hemiazygos vein and draining into the coronary sinus via persistent left superior vena cava: case report, Int. J. Cardiol. 93 (2004) 293–295. Z. Yi, J.S. Sidhu, J. Cheng, A successful implantation of a dual-chambers cardioverter defibrillator for a patient with severe tortuous persistent left superior vena cava, Int. J. Cardiol. 133 (2009) e109–e110. K. Sakabe, N. Fukuda, K. Wakayama, T. Nada, H. Shinohara, Y. Tamura, Radiofrequency catheter ablation for atrioventricular nodal reentrant tachycardia in a patient with persistent left superior vena cava, Int. J. Cardiol. 95 (2004) 355–357. Y. Hirai, C.C. Chou, M.S. Wen, Catheter ablation of atrioventricular nodal reentrant tachycardia in a patient with complete situs inversus, atrial septal defect and "inverse" persistent left superior vena cava, Int. J. Cardiol. 115 (2007) e12–e14. M. Rivero-Ayerza, Y. van Belle, J. Mekel, L.J. Jordaens, Left ventricular lead implantation assisted by magnetic navigation in a patient with a persistent left superior vena cava, Int. J. Cardiol. 116 (2007) e15–e17.
