A Novel Method of Placing Right Ventricular Leads in Patients With Persistent Left Superior Vena Cava Using a Conventional J Stylet

Background

Locating pacemaker electrodes can become complicated by congenital abnormalities such as persistent left superior vena cava (LSVC).

Objective

To evaluate a technique for the implanting of ventricular electrode in patients with persistent LSVC.

Materials and Methods

The study was carried out from June 2001 to June 2010 involving all patients who were admitted to the Hospital Universitario Mayor, Instituto de Corazon de Bogota and Hospital Universitario Clinica San Rafael (Bogota-Colombia) for implanting pacemakers or cardiac defibrillators. LSVC was diagnosed by fluoroscopic observation (anterior-posterior view) of the course of the stylet. Four steps were followed: 1) Move the electrode with a straight stylet to the right atrium. 2) Change the straight stylet by a conventional J stylet and push the electrode to the lateral or anterolateral wall of the right atrium. 3) Remove the guide 3-5 cm and 4) Push the electrode which crosses the tricuspid valve into the right ventricle and finally deploy the active fixation mechanism.

Results

A total of 1198 patients were admitted for pacemaker or cardiac defibrillator implant during the 9-year study period, 1114 received a left subclavian venous approach. There were 573 males and 541 females. Persistent LSVC was found in five patients (0.45%) Fluoroscopy time for implanting the ventricular electrode ranged from 60 to 250 seconds, 40 to 92 minutes being taken to complete the whole procedure.

Conclusion

We present a simple and rapid technique for electrode placement in patients with LSVC using usual J guide and active fixation electrodes with high success.     

Persistent left superior vena cava: Review of embryologic anatomy and considerations for cardiopulmonary bypass

The purpose of this report is to alert the perfusionist to the anatomy of persistent left superior vena cava (PLSVC) and the intraoperative complications that this anomaly may present. The perfusionist should be able to devise a venous circuit that will accommodate three cannulae. He should also be aware that, during cardiopulmonary bypass, a copious volume of deoxygenated blood from the left heart sump, with simultaneous cerebral congestion, may signal the presence of undocumented PLSVC.     

A curious case of impossible coronary sinus cannulation

A 40-year-old male, diagnosed to have WPW syndrome and symptomatic with recurrent palpitations, was taken up for radiofrequency ablation. There was difficulty in coronary sinus cannulation. Coronary venogram revealed coronary sinus atresia with persistent left superior vena cava, and collateral venous pathways draining into the right atrium. This case is discussed for the rare coronary venous anomaly, its embryology and the difficulties in the management during electrophysiological studies.     

Wolff-Parkinson-White syndrome with an unroofed coronary sinus without persistent left superior vena cava treated with catheter cryoablation

Coronary sinus anomalies are rare congenital defects which are usually coexistent with a persistent left superior vena cava and may be associated with cardiac arrhythmias. We report an unroofed coronary sinus without persistent left superior vena cava diagnosed during a catheter ablation procedure for Wolff-Parkinson-White syndrome. Diagnostic and therapeutic options and outcomes are discussed. This condition is of relevance to electrophysiologists performing catheter-based procedures, as well as cardiologists implanting coronary sinus pacing leads, who may encounter this anomaly in their practice.     

Left superior vena cava with atrial displacement.

Two cadavers were dissected showing persistence of left-sided superior vena cava with atrial displacement and inversion of the venous drainage from the body wall (azygos system of veins). The presence of atrial displacement in relation to a persistent left superior vena cava observed in this study lends support to the view that haemodynamic factors influence the morphogenesis and development of the heart. The development of an asymmetrical venous pattern from a symmetrical venous drainage may be influenced by the same factors which influence the arterial end of the primitive heart tube.     

Usefulness of a lead delivery system consisting of a fixed-shaped sheath and a lumenless bipolar lead in a patient with absent right and persistent left superior vena cava: A case report

We report the case of an 84-year-old female with symptomatic bradycardia due to a complete atrioventricular block, who carried absent right and persistent left superior vena cava (SVC). Implantation of a pacing lead, particularly within the right ventricle (RV) in a patient with this venous anomaly is accompanied by technical difficulties. However, the apparatus consisting of a fixed-curve sheath (Model C315-S10, Medtronic, Inc., Minneapolis, MN, USA) and a lumenless fixed-screw pacing lead (Model 3830, Medtronic), allowed a rapid delivery into the RV without any complications. By rotating the Model C315-S10 sheath in the counterclockwise direction in the right atrium, its tip faced the tricuspid orifice, advanced across the tricuspid valve and confronted the RV lower septum near the apex. Then the RV-lead was fixed with acceptable pacing and sensing parameters. Utilizing a lumenless pacing lead and a preformed sheath to deliver it is a novel approach that could be helpful in pacemaker implantation in patients with absent right and persistent left SVC.     

Symptomatic capillary telangiectasia of the pons and intracerebral developmental venous anomaly - A rare association

Various combinations of vascular malformations of the brain in one lesion have been reported, while others seem to be very rare. In this report, the authors discuss the case of a coexistence of an capillary telangiectasia of the pons and intracerebral venous anomaly. To our knowledge, this is the first report of coexistence of a capillary telangiectasia of the pons and intracerebral venous anomaly apparted from each other. These discrete vascular malformations of the brain raise attention on possible interrelations in the pathogenesis of these entities. We report a case of pontine capillary telangiectasia and intracerebral venous anomaly in a 42-year-old woman with a right side facial palsy. Hight field magnetic resonance imaging suggested presence of a capillary telangiectasia of the pons. Another lesion in the left frontal gyrus was attributable to the venous anomaly. Along with neuroradiological findings, results of the somatosensor evoked potentials, brain stem auditory potentials, laboratory analysis including blood, cerebrospinal fluid and urine investigation are demonstrated. Awareness of the magnetic resonance imaging finding of the capillary telangiectasias and of the venous anomalies may help in defining clinical correlates of this vascular malformations, while the follow up of these malformations might help to asses risk of vascular rupture. We and others previously selects capillary telangiectasia and venous anomaly in two discrete entities. Coexistence of these malformations in the brain apparted from each other appear to be very rare and raise attention on possible interactions in their natural history and pathogenesis.     

An unusual ‘bow tie’ image in pacemaker implantation

Upper venous system anatomic variations may cause difficulties during cardiac pacemaker implantation. Persistent left superior vena cava (PLSVC) and absent right superior vena cava could be an arrhythmogenic source of atrial arrhythmias and cardiac conduction disease. We represent dual-chamber pacemaker implantation in a patient with a very rare upper venous system anomaly, paroxysmal atrial fibrillation, sick sinus syndrome, that cause unusual fluoroscopic image.     

A case of primary aldosteronism with chronic renal failure undergoing hemodialysis treatment

A 56-year-old man with primary aldosteronism and chronic renal failure undergoing hemodialysis is described. He complained of numbness of the extremities and showed persistent hypopotassemia in spite of anuria. In the endocrinological examination, a very high plasma aldosterone concentration was observed, while plasma renin activity was within the normal range. From the abdominal Computed Tomography (CT), adrenal scintigraphy, and segmental venous sampling data, he was diagnosed as primary aldosteronism due to left adrenocortical adenoma. In this case, hypopotassemia could not be explained by potassium loss through the kidneys, which suggests potassium excretion in the gastrointestinal tract as the mechanism of hypopotassemia. This was clearly shown from a potassium-balance study and the results of spironolactone administration. Our report is on the first case showing hypopotassemia due to primary aldosteronism in spite of anuria. If a patient treated with maintenance dialysis should have persistent hypopotassemia, as in the present report, it is necessary to consider an association with primary aldosteronism.     

Atresia of the right atrial ostium of the coronary sinus

A case of asymptomatic congenital occlusion of the ostium of the coronary sinus is described. The myocardial venous drainage was maintained via a persistent left superior vena cava as well via ectatic, widened atrial veins of the dorsal wall of the left atrium. The study shows that complete ostial occlusion of the coronary sinus does not reduce cardiac venous drainage. The view of the literature allows a comparison with the comprehensive classification of coronary sinus anomalies.     

Radiofrequency Catheter Ablation Of Atrioventricular Nodal Reentry Tachycardia In A Patient With Inferior Vena Cava Anomaly

Curative radiofrequency catheter modification of the slow pathway is the recommended therapy for patients suffering from recurrent symptomatic atrioventricular nodal reentry tachycardia. This is usually performed via femoral vein and the inferior vena cava (IVC). Presence of venous occlusion or complex venous anomaly involving the IVC may preclude this approach. Here, we report a case with a complex venous anomaly involving the inferior vena cava, who underwent electrophysiological study and successful radiofrequency ablation by an alternative approach.     

Implantation of a resynchronization implantable cardioverter defibrillator in a patient with persistent left superior vena cava

Implantation of resynchronization implantable cardioverter defibrillator was performed in a patient with persistent left superior vena cava. A dual coil defibrillation lead was inserted in the right ventricle apex via a small innominate vein. Left ventricular and atrial leads were implanted through persistent left superior vena cava. Left ventricular lead was easily implanted into the postero lateral vein. Pacing thresholds and sensing values were excellent and remained stable at 18 months follow-up.Presence of persistent left superior vena cava generally makes transvenous lead implantation difficult. However when a favorable coronary sinus anatomy is also present, it may facilitate left ventricular lead positioning in the coronary sinus branches.     

Persistent left superior caval vein draining into right atrium,but not through the coronary sinus

Persistence of the left superior caval vein is the most commonly reported thoracic venous anomaly. The vein usually drains into the right atrium through the coronary sinus, reflecting its developmental origin. We describe an unusual variant, in which the vein drained directly into the right atrium.     

Association of the left common ostium with clinical outcome after pulmonary vein isolation in atrial fibrillation

IntroductionElectrical pulmonary vein isolation (PVI) is used for the invasive treatment of atrial fibrillation (AF). However, despite the procedure’s technical evolution, the rate of AF recurrence due to electrical reconnection of the PVs is high. The aims of this study was to assess the influence of left common pulmonary venous ostium (LCO) on clinical outcomes following PVI.MethodsRetrospective cohort of 254 patients who underwent the first procedure of PVI from the years 2013–2018 was assessed. Patients with persistent AF of long duration and extra-pulmonary focus associated with triggers for arrhythmia were excluded. Patients were stratified into two groups according to the presence of a LCO and received follow up for atrial tachyarrhythmia-free survival. The mean follow-up period was 28 ± 1.73 months.ResultsThe majority were men (68.5%), with a mean age of 54 ± 12 years. With respect to the atrial anatomy, LCO occurred in 23.6% of cases after pulmonary venous angiotomography. The arrhythmia-free survival rate was 79.5% in the follow-up period. The Cox regression model was utilized and the adjusted hazard ratio for LCO was 0.36 (95% CI 0.15–0.87; p = 0.02) in terms of age, body mass index, left atrium diameter, bi-directional blocking of the cavotricuspid isthmus, persistent AF, left ventricular ejection fraction adjusted model.ConclusionAnatomic abnormality with the presence of the LCO is present in a quarter of patients undergoing AF ablation, which is associated with a lower rate of arrhythmia recurrence in our population.     

Anomalous caudal vena cava passing through the vertebral canal in a calf

A 15-day-old female Holstein-Friesian calf with an anomalous caudal vena cava was examined macroscopically, roentgenologically, and histologically. The calf, weighing 43 kg, had severe scoliosis. A common renal vein merged into a single venous trunk formed by the union of the left and right common iliac veins. The trunk entered the vertebral canal through the left intervertebral foramen formed by the last (13th) thoracic and the first lumbar vertebrae. The trunk continued along the ventral side of the narrowing spinal cord inside the canal, and then ran out the left intervertebral foramen formed by the 8th and 9th thoracic vertebrae and emptied via the right azygos vein into the cranial vena cava. In contrast, the hepatic vein passed through the foramen vena cava independently of the trunk and entered the right atrium directly. The pathogenesis of the present anomaly may be explained as follows: The right subcardinal vein, failing to make connection with the liver, shunted directly into the right azygos vein derived from the right supracardinal vein. The body axis began to curve before ossification of the vertebrae occurred. Consequently, the developing right supracardinal vein, located close to the spinal cord, is thought to have become enclosed in the vertebrae with the spinal cord during the early fetal stages.     

CORRECTION OF ANOMALOUS VENOUS RETURN FROM THE RIGHT LUNG TO THE INFERIOR VENA CAVA (SCIMITAR DEFORMITY)

Anomalous pulmonary venous drainage to the inferior vena cava is a rare congenital cardiac defect. Oxygenated blood from the right lung enters the right atrium resulting in a left-to-right shunt. Because the radiographic shadow of the anomalous vein resembles a curved saber, this defect has been called the "scimitar" deformity. From 1958 through June 30, 1975, 11 patients underwent surgical correction of this anomaly at our institution with 10 survivors. Diagnosis was made by routine roentgenography of the chest in all but one patient. Eight patients had total correction which consisted of implanting the anomalous vein into the right atrium, opening the interatrial septum and applying a patch graft as a baffle to direct pulmonary venous blood into the left atrium. Five patients had associated cardiac defects which were also repaired. Three patients underwent pneumonectomy and all survived. The only operative death occurred in a 5-year-old female with an atrial septal defect and endocardial cushion defect. We believe the existence of a large left-to-right shunt justifies surgical intervention. The prognosis appears to depend upon the presence of other cardiac or pulmonary anomalies.     

White cell accumulation in dependent legs of patients with venous hypertension: a possible mechanism for trophic changes in the skin

The mechanism by which chronic venous insufficiency and venous hypertension are associated with ulceration of the legs is not yet understood. To investigate this mechanism further accumulation of white cells in the dependent legs of normal volunteers, patients awaiting surgery for simple varicose veins, and patients with chronic venous insufficiency was studied. About 24% fewer white cells than in normal subjects left the dependent foot of patients with venous hypertension, and this trapping of white cells, was reversed when the foot was raised; similar changes were not observed in normal subjects or patients with varicose veins.The trophic skin changes typically seen in patients with venous hypertension may be aggravated by damage caused by the repeated accumulation of white cells in the microcirculation.     

Effective vascular compliance of dogs in acute heart failure.

Effective vascular compliance was measured repeatedly in dogs without circulatory arrest utilizing a closed-circuit venous bypass system and constant cardiac output. Compliance, determined by the delta V/delta P relationship at the end of a 1-min infusion of 5% of the circulating volume into the inferior vena cava, was independent of the initial venous pressure, total circulating volume and systemic arterial pressure. It remained constant over a 3 h experimental period at 1.55 plus or minus 0.05 ml (mm Hg)-1-kb-1 body weight. Elevation of mean left atrial pressure and mean pulmonary arterial pressure by gradual aortic constriction was associated with a large and significant reduction in vascular compliance to a value of 1.14 plus or minus 0.06 ml (mm Hg)-1-kg-1 after 2 h. This reduction was independent of the initial venous pressure and total circulating volume but was associated with the changes in left atrial and pulmonary artery pressures and an increase in plasma catecholamine concentrations. The mechanism responsible for the reduction in effective compliance is not clear from the present experiments. Increased circulating catecholamines and sympathetic nerve traffic resulting from baro- and volume receptor stimulation in the vascular tree may be the causative mechanism.     

大鼠心肌重塑过程中Axin蛋白质的表达变化

为观察大鼠心肌重塑过程中Axin蛋白质表达水平的变化,实验用颈静脉输注去甲肾上腺素(NE)和动静脉造瘘(AVF)方法复制大鼠心肌重塑病理模型,采用超声心动术检测心脏结构和收缩功能。取病理模型大鼠左心室以及分离培养的成年大鼠心肌成纤维细胞,采用Wester blot技术检测Axin蛋白质的表达水平。结果观察到,在颈静脉输注NE 3d后,大鼠心脏发生向心性心肌肥厚和心肌纤维化,其左心室的Axin蛋白表达水平较对照组显著升高。A-V造瘘术一周后引起大鼠离心性心肌肥厚,心肌无明显纤维化,心肌Axin表达量与对照相比无显著变化。在分离培养的成年大鼠心肌成纤维细胞,NE处理24h能明显升高Axin蛋白的表达水平。上述结果表明,大鼠心脏有Axin蛋白质表达,NE致大鼠心肌重塑过程中Axin蛋白表达显著增加,可能与该过程的心肌纤维化有关。