Total transvenous approach to pacing and defibrillation after Ebstein's anomaly

We describe the successful use of a percutaneous, transvenous endocardial approach to atrioventricular pacing and cardiac defibrillation in an adult born with Ebstein's anomaly who had undergone tricuspid valve repair. The patient has systolic left ventricular dysfunction, congestive heart failure, and sinus node dysfunction. Ventricular pacing and sensing was obtained with a bipolar lead placed in the inferolateral cardiac vein; atrial pacing was obtained at the low interatrial septum. Internal cardiac defibrillation was achieved with a coil lead placed in the middle cardiac vein and the active can in the left retro mammary pre-pectoral position. With this approach, we avoided a thoracotomy and epicardial patch in a patient whose previous tricuspid valve surgery precluded an endocardial right ventricular lead position.