Figure 2 Three-dimensional (3D) Computed Tomography reconstruction of
the “lost” superior vena cava and superior right atrium. In 3d
reconstruction they are invisible due to thrombosis
The patient thus underwent a MTPS implantation. The implantation of the
device was performed by the means of standard technique with some
additional technical tricks. A first challenging operative condition
resulted due to the impossibility of guidewire advancement up to
superior vena cava, generally useful to provide a firm support for the
safe advancement of the introducer and dilator over the wire up to the
mid right atrium. To explore the in vivo anatomy of the right atrial
chamber, the introducer was left in place inside the inferior vena cava
and a pigtail catheter was advanced through the introducer up to the
right atrium. Then, a small amount of contrast media was injected inside
the right atrium to obtain a real time image of the anatomy and volume
of the residual atrial chamber to assess the operating space
(supplementary video). Subsequently, a gentle and careful manipulation
of the large delivery system inside right atrium was performed in order
to avoid crushing against the thrombotic invasion coming from the roof
of atrium, therefore potentially causing a threatening mobilization of
emboli. Finally, MTPS was successfully deployed in the mid septum, with
optimal electrical parameters and without complications (figure 3).