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).