A 69-year-old man with a previous history of bicuspid aortic valve replacement was referred for dual-chamber pacemaker implantation. Because the patient was left-handed, a right-sided pectoral implantation was attempted. The advancement of the guide wire from the right subclavian vein to the superior vena cava showed an unusual route on fluoroscopy along the left cardiac border (Panel A). The incidental finding of a persistent left superior vena cava leading to a dilated coronary sinus was subsequently verified on venography (Panel B). Injection of contrast media through an Amplatz catheter revealed the absence of right superior vena cava (Panel C). Thereafter, a long (85 cm) active fixation lead was manipulated to enter the right ventricle by the use of the wide-loop technique and fixed in the ventricular wall. A second lead was screwed in the atrial wall (Panels D and E). When the presence of isolated persistent left superior vena cava is anticipated, a right-sided pectoral implantation of a pacemaker system should be preferred to facilitate leads manipulation and suitable positioning.
Conflict of interest: none declared.
