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\begin{document}

\title{A NOVEL TECHNIQUE OF PLACING RIGHT VENTRICLE LEADS IN PATIENTS WITH
PERSISTENT LEFT SUPERIOR VENA CAVA}



\author[1]{Laura García-Cano}%
\author[1]{Thomas Brouzet}%
\author[1]{Jose Luis Ibañez Criado}%
\author[1]{Amaya García-Fernández}%
\author[2]{Marta Monteagudo-Viana}%
\author[1]{Juan Gabriel Martinez}%
\author[1]{Alicia Ibañez Criado}%
\affil[1]{Hospital General Universitari d'Alacant Servicio de Cardiologia}%
\affil[2]{Hospital Universitari Sant Joan d'Alacant}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\selectlanguage{english}
\begin{abstract}
\emph{Background}: Persistent left superior vena cava is the most common
thoracic venous anomaly. It is usually asymptomatic, but it can make it
difficult to implant intracardiac devices . \emph{Case presentation}: We
present a novel technique to facilitate right ventricular lead
implantation in two patients with persistent left superior vena cava and
the absence of the right superior vena cava. We used a fixed-curve
Selectra 3D sheath (Biotronik), orienting the sheath towards the
tricuspid valve by rotating it in a counter-clockwise direction. During
follow-up, the electrodes remained stable. \emph{Discussion}: Our
technique was safe, simple and feasible for patients with this complex
venous anatomy.%
\end{abstract}%



\sloppy


\textbf{A NOVEL TECHNIQUE OF PLACING RIGHT VENTRICLE LEADS IN PATIENTS
WITH PERSISTENT LEFT SUPERIOR VENA CAVA}

Thomas Andr\selectlanguage{ngerman}é Brouzet\textsuperscript{1} (MD, PhD), Laura
García-Cano\textsuperscript{1} (MD), José Luis
Ibáñez-Criado\textsuperscript{1} (MD, PhD), Amaya
García-Fernández\textsuperscript{1} (MD, PhD), Marta
Monteagudo-Viana\textsuperscript{2} (MD, PhD), Juan Gabriel
Martínez-Martínez\textsuperscript{1} (MD, PhD), Alicia
Ibáñez-Criado\textsuperscript{1} (MD, PhD).

\textsuperscript{1}Arrhythmia Unit, Cardiology Service, Alicante General
University Hospital. Alicante Health and Biomedical Research Institute
(ISABIAL), Alicante, Spain.

\textsuperscript{2}Cardiology Service, Sant Joan d'Alacant University
Hospital. Alicante, Spain.

Dr. Thomas André Brouzet. Institution: Alicante General University
Hospital, Spain. E-mail: thomasbrouzet@hotmail.com.

Dra. Laura García-Cano (corresponding author). Institution: Alicante
General University Hospital, Spain. Postal address: Calle Pintor Baeza
Nº 12 (Alicante, Spain). CP 03010. E-mail: lauracano1@hotmail.com.

Dr. José Luis Ibáñez-Criado. Institution: Alicante General University
Hospital, Spain. E-mail: ppluic@hotmail.com.

Dra. Amaya García-Fernández. Institution: Alicante General University
Hospital, Spain. E-mail: ama\_garcia@hotmail.com.

Dra. Marta Monteagudo-Viana. Institution: Sant Joan d'Alacant University
Hospital. Alicante, Spain. E-mail: monvia80@hotmail.com.

Dr. Juan Gabriel Martínez-Martínez. Institution: Alicante General
University Hospital, Spain. E-mail: martinez.juangabriel@gmail.com.

Dra. Alicia Ibáñez-Criado. Institution: Alicante General University
Hospital, Spain. E-mail: aliciaicriado@gmail.com.

\textbf{Disclosures} : The authors have nothing to disclose.

\textbf{Funding} : This research received no grant from any funding
agency in the public, commercial or not-for-profit sectors.

\textbf{Patient consent statement} : all patients gave their consent
after being informed of the purpose of this paper.

\textbf{Author contributions:} LG, TB and JI contributed to the study
conception and design. LG and TB contributed to the acquisition of data.
LG, TB, and JI had the lead in preparing the manuscript. AG, MM, AI, and
JM critically revised the manuscript. TB and LG were involved in the
clinical management of the patient. All authors read and approved the
final manuscript.

\textbf{Abstract}

\emph{Background} : Persistent left superior vena cava is the most
common thoracic venous anomaly. It is usually asymptomatic, but it can
make it difficult to implant intracardiac devices .

\emph{Case presentation} : We present a novel technique to facilitate
right ventricular lead implantation in two patients with persistent left
superior vena cava and the absence of the right superior vena cava. We
used a fixed-curve Selectra 3D sheath (Biotronik), orienting the sheath
towards the tricuspid valve by rotating it in a counter-clockwise
direction. During follow-up, the electrodes remained stable.

\emph{Discussion} : Our technique was safe, simple and feasible for
patients with this complex venous anatomy.

\textbf{Keywords:} Persistent left superior vena cava; Intracardiac
device; Selectra 3D Sheath; Left bundle branch area pacing.

\textbf{Abbreviations:}

PLSVC: persistent left superior vena cava.

RSVC: right superior vena cava.

RV: right ventricle.

ICD: implantable cardioverter-defibrillator.

RA: right atrium.

CS: coronary sinus.

TV: tricuspid valve.

\textbf{Background}

Persistent left superior vena cava (PLSVC) is the most common thoracic
venous anomaly, being present in 0.3-0.5\% of the general
population\textsuperscript{1}. Most patients also have a right superior
vena cava (RSVC), which is usually connected to the PLSVC via a left
brachiocephalic vein\textsuperscript{2}. However, in 18\% of cases the
VCSD is absent\textsuperscript{2}. Patients with PLSVC are usually
asymptomatic. The condition is generally discovered incidentally in
imaging techniques, or during central venous cannulation
procedures\textsuperscript{1,2}.

Clinical experience on intracardiac device implantation in patients with
PLSVC is scant and limited to isolated case
reports\textsuperscript{3,4,5}. In this paper, we present two cases of
PLSVC with the absence of RSVC, wherein we performed intracardiac device
implantation using a novel technique to introduce and place the leads
into the right ventricle (RV).

\textbf{Case 1}

We present the case of a 70-year-old man with a history of chronic
coronary syndrome, who was admitted due to recurrent syncope. The ECG
showed sinus rhythm with right bundle branch block. A cardiac magnetic
resonance imaging was requested, which reported a dilated cardiomyopathy
of ischemic origin with moderate ventricular dysfunction. As an
incidental finding, a PLSVC with agenesis of RSVC was observed, draining
into a dilated coronary sinus (CS). Therefore, an implantable
cardioverter-defibrillator (ICD) was indicated. Due to the absence of
RSVC, left axillary vein puncture was performed without incident.
Several attempts were made to introduce the ICD lead into the RV apex
through different modifications of the curve of the stylet; however, it
was repeatedly directed towards the RV outflow tract possibly due to
coil stiffness. Finally, we decided to use a Selectra 3D 65cm sheath
(Biotronik, SE\&Co), commonly used for left bundle branch area pacing.
With a 0.375mm guidewire, we reached the right atrium (RA) through the
CS, and then we advanced the sheath through it. Once in RA, by
counter-clockwise rotation, we were able to orient the tip of the sheath
towards the tricuspid valve (TV) and cross into the RV without
difficulty. We subsequently removed the guidewire and advanced a Durata
7122-Q 65cm lead (Abbott Medical S.A.) up to the RV apex. After
confirming adequate detection and stimulation parameters, the sheath was
removed using the usual peel-away technique. The lead in RA was placed
in the right appendage, without requiring the use of a sheath. All
parameters remained stable during follow-up, with no complications
(Figure 1).

\textbf{Case 2}

A 51-year-old man with a history of mild rheumatic mitral stenosis was
admitted to a secondary hospital due to a symptomatic third-degree
atrioventricular block with an escape rhythm of 40 bpm. It was decided
to implant a pacemaker; however, during the procedure the implanters
presented difficulties in advancing the guidewire. Venography was
performed, which evidenced a PLSVC with drainage in the CS, and absence
of RSVC. Our centre was contacted after these findings. Left axillary
venous access was performed, and due to our previous experience, a
Selectra 3D 65cm sheath (Biotronik, SE\&Co) was used from the beginning
to facilitate the advancement of the lead to the RV. As in the previous
case, we accessed RA through the CS and performed a counter-clockwise
rotation to orient the sheath towards the TV and advance the guidewire
through it. The baseline ECG showed a left bundle branch block, so we
decided to pace the left bundle branch area. Using counter-clockwise
rotation, we supported the sheath against the interventricular septum
and inserted a Solia S60 electrode (Biotronik) in the usual way. To
check the optimal position and depth of the lead, left and right
anterior oblique projections were made after contrast injection. The RA
electrode was implanted without difficulty in the right appendage. The
values of impedance, threshold, and R-wave amplitude were verified
during the procedure. The ECG after implantation showed QRS narrowing up
to 140ms with a QR pattern in V1. During follow-up, the leads remained
stable, with no complications (Figures 2 and 3).

\textbf{Discussion}

The presence of PLSVC associated with the absence of RSVC is rare, and
its appearance is related to alterations in the development of the
venous system during pregnancy\textsuperscript{6}. It is usually
asymptomatic but may complicate the implantation of intracardiac
devices. The main problem is the presence of an acute angle between the
CS ostium and the TV, preventing adequate orientation of the lead
towards the RV\textsuperscript{7}. This is partially resolved by right
venous access through the RSVC. However, in patients with no RSVC in
whom the RV cannot be accessed by left venous access, an epicardial
approach and subsequent tunnelling should be used\textsuperscript{5}. To
avoid epicardial access and facilitate implantation, several methods
have been proposed. The most common technique consists of curving the
stylets at different angles\textsuperscript{8}. However, it is not
always effective as it requires considerable operator experience and
skill, in addition to the risk of RA perforation with electrode
manipulation\textsuperscript{7}. Subsequently, two alternative methods
have been described, using a sheath for CS cannulation during cardiac
resynchronization therapy\textsuperscript{9}, or a Medtronic C315-S10
sheath frequently used for implantation of leads in the area of His or
the left bundle branch area\textsuperscript{7}, allowing both to orient
and advance the electrodes towards the RV apex.

We present two patients diagnosed with PLSVC and the absence of RSVC who
required the implantation of an intracardiac device. In both, a novel
technique was used, involving the use of Selectra 3D sheath (Biotronik,
SE\&Co) to facilitate the advancement of the lead to the RV by
performing a counter-clockwise rotation. In addition, in one of the
cases, lead implantation was achieved in the left bundle branch area,
with adequate electrocardiographic and pacing parameters that were
maintained at follow-up.

This paper presents the initial report on the use of this sheath and the
insertion of a lead in the left bundle branch area in patients with
PLSVC. This is a safe and easy technique to perform, and we consider it
an option to be considered in patients with complex venous anatomy,
saving procedural and fluoroscopy time.

\textbf{References}

\begin{enumerate}
\tightlist
\item
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\end{enumerate}

\textbf{Figures}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1.} Chest radiograph after ICD implantation (A:
posteroanterior view; B: lateral view). The ICD lead is located in the
apex of the right ventricle, and the atrial lead in the right appendage.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2.} Chest X-ray 3 months postimplantation (A:
posteroanterior view; B: lateral view), with ventricular lead in the the
left bundle branch area, and the atrial lead in the right appendage.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 3.} A: ECG on admission, with third-degree
atrioventricular block and escape rhythm with left bundle branch block
morphology. B: Post-implantation ECG with QRS narrowing of up to 140ms
and a QS pattern in V1.

\selectlanguage{english}
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