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Year : 2007  |  Volume : 53  |  Issue : 1  |  Page : 76-77

Transvenous right ventricular pacing through coronary sinus in a patient with persistent left superior vena cava

1 Department of Cardiology, SCTIMST, Thiruvananthapuram, Kerala, India
2 Escorts Hospital, Amritsar, Punjab, India

Correspondence Address:
N Namboodiri
Department of Cardiology, SCTIMST, Thiruvananthapuram, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0022-3859.30338

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How to cite this article:
Namboodiri N, Verma P K. Transvenous right ventricular pacing through coronary sinus in a patient with persistent left superior vena cava. J Postgrad Med 2007;53:76-7

How to cite this URL:
Namboodiri N, Verma P K. Transvenous right ventricular pacing through coronary sinus in a patient with persistent left superior vena cava. J Postgrad Med [serial online] 2007 [cited 2023 Jun 1];53:76-7. Available from:


A 60-year-old lady presented with two episodes of syncope in the last four weeks. Electrocardiogram showed complete heart block with ventricular escape rhythm at 30/min. Transvenous permanent pacemaker implantation (PPI) was planned. Using Seldinger's technique, guide wire was introduced through left subclavian vein, which entered right atrium (RA) via persistent left superior vena cava (PLSVC) and coronary sinus (CS) [Figure - 1][Figure - 2]. A tined pacing lead was advanced into the RA. The straight stylet was removed from the lead and replaced with a preshaped stylet. A J-loop was formed in the terminal 5 cm of the stylet that directed the lead anterio-inferiorly across the tricuspid valve into the right ventricular (RV) inflow area. The tined lead was advanced to the apex of RV where its anchorage was confirmed on withdrawing the stylet and its position was stabilized by forming a loop against the lateral wall of the right atrium. The lead parameters were found satisfactory. At 30 months of follow-up, the pacemaker continues to function normally with optimal parameters.

Manipulation of the transvenous lead through this unusual venous route is often associated with complications. Advancing the lead through this tortuous route can subject the lead to acute bend thereby predisposing to fracture and displacement of lead and failure of pacing. Once RA is reached, further placement of the lead into the RV becomes difficult, because the tip of the lead tends to be deflected away from the tricuspid orifice. Harris et al . used a soft electrode wire (Elema) with a heavy tip to guide the wire into the RV by gravity in the left lateral position.[1] It has been suggested that stylet shaping and use of active fixation leads could help the proper lead anchorage.[2],[3],[4],[5],[6] Dirix et al , during implantation of dual chamber pacemaker via PLSVC, used a J-shaped atrial lead as the ventricular lead and implanted it in the anteroapical part of the RV.[2] Zerbe et al . reshaped the end of the stylet into a 3-4 cm wide pigtail loop and placed the lead in the RV in four of their patients.[3] Hsiao et al . demonstrated an open J-loop technique wherein the stylet was placed in a semicircular curve in the RA with the tip of the stylet directed to the orifice of the tricuspid valve anterioinferiorly. While the reshaped stylet was held and fixed in the RA, the lead was advanced into the RV and was implanted into the RV apex.[4] The use of a steerable stylet for similar purpose was reported by Hanna-Mousa et al .[5] Recently, Srimannarayana et al have described the use of the atrial 'J' stylet to guide the tined, ventricular lead across the tricuspid valve to reach the right ventricular inflow portion.[6]

This case is being reported to highlight the technical difficulties that may be encountered in PPI through left subclavian vein, the feasibility of achieving a good position of the lead in RV apex when introduced via PLSVC and the long-term success of this technically demanding procedure in our patient.

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1.Harris A, Gialafos J, Jefferson K. Transvenous pacing in presence of anomalous venous return to heart. Br Heart J 1972;34: 1189-91.  Back to cited text no. 1  [PUBMED]  
2.Dirix LY, Kerssehot IE, Fierens H, Goethals MA, Van Daele G, Claessen G. Implantation of a dual chamber pacemaker in a patient with persistent left superior vena cava. Pacing Clin Electrophysiol 1988;11:343-5.  Back to cited text no. 2    
3.Zerbe F, Bornakowski J, Sarnowski W. Pacemaker electrode implantation in patient with left superior vena cava. Br Heart J 1992;67:65-6.  Back to cited text no. 3  [PUBMED]  
4.Hsiao HC, Kong CW, Wang JJ, Chan WL, Wang SP, Chang MS, et al . Right ventricular electrode lead implantation via a persistent left superior vena cava. An improved technique. Angiology 1997;48: 919-23.  Back to cited text no. 4    
5.Hanna-Moussa S, Johnson V, Raina A. Implantation of a dual-chamber pacemaker in a patient with persistent left superior vena cava using a steerable stylet. J Invasive Cardiol 2002;14:192-3.  Back to cited text no. 5  [PUBMED]  
6.Srimannarayana J, Varma RS, Satheesh S, Anilkumar R, Balachander J. Transvenous permanent pacemaker implantation through left superior vena cava. Indian Heart J 2004;56:346-8.  Back to cited text no. 6  [PUBMED]  


[Figure - 1], [Figure - 2]

This article has been cited by
1 Persistent Left Superior Vena Cava Diagnosed by Bedside Echocardiography
Walpot, J., Pasteuning, W.H., van Zwienen, J.
Journal of Emergency Medicine. 2010; 38(5): 638-641
2 Persistent Left Superior Vena Cava Diagnosed by Bedside Echocardiography
Jeroen Walpot,W. Hans Pasteuning,Jan van Zwienen
The Journal of Emergency Medicine. 2010; 38(5): 638
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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
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