Technical considerations for CRT-D implantation in different varieties of persistent left superior vena cava

The persistent left superior vena cava (PLSVC) is usually asymptomatic and creates a challenge when detected incidentally during cardiac resynchronization therapy defibrillator (CRT-D) implantation. The purpose of our cases is to show different anatomical variables of PLSVC and different strategies used for CRT-D implantation.

Four cases of PLSVC were presented. Pre-procedural bilateral venography was done to define anatomical variant of PLSVC. The side of approach and vein of approach were chosen according to the anatomical variant. Major challenges, electrical parameters, procedural times, long-term follow up, and complications were addressed.

Two cases were de novo CRT-D implantation. One case was an extraction/re-implantation of the coil lead, and one case was an upgrading. In one case, CRT-D implantation was followed by AVN ablation. All cases had successful devices implantation. Two cases had isolated PLSVC: one of them had right approach and the other had left approach. One case had double SVC with no connecting brachiocephalic veins and underwent a left-sided approach. One case had double SVC with a small connecting brachiocephalic vein and had a left approach for implantation with using the small brachiocephalic vein for the RV lead. Electrical parameters were acceptable for all leads implanted. Long-term follow-up was done for 6 months to 5 years. One complication occurred (acute atrial lead dislodgement).

In our case series, the presence of PLSVC did not preclude successful placement of pacemaker/defibrillator leads using standard tools. Bilateral venography helped to decide the side and vein of lead insertion.