Biventricular Pacing via a Persistent Left Superior Vena Cava: Report of Four Cases MAURIZIO GASPARINI, MASSIMO MANTICA, PAOLA GALIMBERTI, FERNANDO COLTORTI, STEFANO SIMONINI, CARLO CERIOTTI, and EDOARDO GRONDA* From the Department of Cardiology, Humanitas Clinical Institute, Rozzano, Milan, Italy
GASPARINI, M., ET AL.: Biventricular Pacing via a Persistent Left Superior Vena Cava: Report of Four Cases. Persistence of left superior vena cava (LSVC) is an uncommon finding during pacemaker implantation, which may be particularly relevant in performing LV transvenous pacing. Rarely, it is further complicated by the presence of atresia of the coronary sinus ostium (CSO). This article reports the authors experience with biventricular pacing (Biv-P) in this unusual clinical setting. From October 1999 to April 2002, 158 patients underwent biventricular pacing. In four of them (mean age 62.2 years), the presence of a persistent LSVC draining into the coronary sinus (CS) was detected at implantation, associated with atresia of the CSO in two patients. A common characteristic was the angiographic finding of a large CS with few tributaries. The LV leads were successfully positioned in the middle cardiac vein in three patients and in a posterolateral vein in one patient. All vessels were large and their cannulation via downstream CS catheterization required the lead to be manipulated through sharp angles. Mean fluoroscopic exposure and procedural times were not significantly different from the overall Biv-P population. In all patients, at a mean follow-up of 11 months, sensing and capture threshold remained stable and a significant decrease in NYHA functional class and increase in LVEF were noted. The direct lead placement in large CS tributaries in the presence of persistent LSVC was feasible and safe. The leads remained stable up to a mean follow-up of nearly 1 year. (PACE 2003; 26[Pt. II]:192–196) congestive heart failure, cardiac resynchronization therapy, persistent left superior vena cava, biventricular pacing Introduction Left ventricular (LV) stimulation using a transvenous lead positioned in the coronary venous system is effective to resynchronize ventricular contractions in patients with severe congestive heart failure (CHF).1,2 Under normal circumstances, the coronary sinus (CS) is approached from a subclavian vein, and the lead is positioned after the performance of occlusive venography. The unexpected presence of a persistent left superior vena cava (LSVC) draining into an enlarged CS may cause technical difficulties when attempting to implant a biventricular pacing (BivP) system. This report describes the authors’ experience, focusing on solutions that may be helpful to perform cardiac resynchronization therapy in the presence of this rare venous anomaly. Patients and Methods Patient Population Two men and two women between the ages of 51 and 77 years, with CHF due to idiopathic dilated cardiomyopathy and in New York Heart Association (NYHA) Class III (left ventricular ejection Address for reprints: Maurizio Gasparini, M.D., Istituto Clinico Humanitas, Via Manzoni, 56-20089 Rozzano, Milano, Italy. Fax: 0039-2-8224-4691; e-mail:
[email protected]
192
fraction [LVEF] 0.20–0.27), underwent Biv-P system implantation and were found to have a persistent LSVC (patients 1–3), or a left intercostal vein (patient 4). Sinus rhythm with complete left bundle branch block (LBBB) was present in patients 1, 2, and 4, while patient 3 had a previously implanted VVIR pacemaker (PM), for atrial fibrillation and a slow ventricular rate. In patients 1 and 2, the persistence of a LSVC was unexpected and recognized when the guidewire, advanced into the left subclavian vein (LSV) in a posteroanterior fluoroscopic, projected to the left side of the spine before reaching the right atrium (RA). In patient 3, the persistence of a LSVC was known since a PM had been previously implanted through the abnormal vessel. In patient 4, a left intercostal vein was detected, a much smaller vessel coursing closer to the spine compared to the persistent LSVC. Venous Angiography In a first angiographic step, the presence of an innominate vein connecting the LSV to the right superior vena cava (RSVC) was examined, since its absence indicates that the entire upper left superior venous circle drains through a persistent LSVC and CS of unusually large size. This situation was encountered in patients 1 and 3. Contrast solution injected through an Attain balloon catheter Model
January 2003, Part II
PACE, Vol. 26
BIVENTRICULAR PACING VIA LSVC
6215 (Medtronic Inc., Minneapolis, MN, USA) advanced into the persistent LSVC did not allow the performance of occlusive venography and visualization of the CS tributaries, since the size of the CS exceeded the inflated balloon 10-mm diameter. Further attempts to visualize the CS tributaries by manual or power injection of contrast material through a pigtail catheter were unsuccessful. In patients 2 and 4 an innominate vein was present and the RA was easily reached, though standard catheter manipulation did not allow cannulation of the CS, suggesting the presence of RACS ostium (CSO) atresia. In patient 2, the persistent LSVC was occasionally cannulated by the guidewire and radiographic images of adjacent wires, from the RA and from the CS, were observed. CS atresia was confirmed by CS venography (Fig. 1), along with the presence of a large middle cardiac vein (MCV). In patient 4 the venous phase of coronary angiography was used to confirm the presence of CSO atresia. The CS, whose dimensions and orientation were preserved, drained into the LSV through the
left intercostal vein (Fig. 2), which was successfully cannulated. Lead Selection Given the peculiar venous anatomy, a smallbodied lead with a preshaped, flexible, angled distal end was initially used. In patient 1 an Attain SD lead Model 4189 was advanced through the persistent LSVC to the CS, and a meticulous search for a venous branch was performed by repeated dragging of the lead along the CS walls. After several attempts, the lead was positioned in the MCV with satisfactory sensing and stimulating parameters. The implant was completed with active-fixation leads placed in the RA and the right ventricle (RV), both advanced from the persistent LSVC. The RV lead was affixed to the lateral wall as far as possible from the CS lead tip, after forming a wide angled loop within the RA (Fig. 3). In patient 2, a small-bodied Attain Side-Wire Model 4191 lead was curved at its distal end and used to explore the CS until a previously not
Figure 1. Patient 2. CS atresia was confirmed by venography, with a large MCV, in the RAO 25-degree (panel A) and in LAO 35-degree (panel B) views. The RV lead was temporarily positioned in the IVC. CS = coronary sinus; IVC = inferior vena cava; LAO = left anterior oblique; MCV = middle cardiac vein; RAO = right anterior oblique; RV = right ventricular.
PACE, Vol. 26
January 2003, Part II
193
GASPARINI, ET AL.
Figure 2. Patient 4. Venous phase of the left coronary artery angiography to discover the presence of RA-CS ostium atresia. The marker (*) indicates the presence of a preserved dimension and orientation of the CS draining into the left SVC through the left intercostal vein (arrow). Unsuccessful attempts to cannulate the CS from the RA were made with a 20-electrode electrophysiological catheter. LAO 35-degree projection. CS = coronary sinus; LAO = left anterior oblique; RA = right atrium; SVC = superior vena cava.
visualized posterolateral branch was entered. The implant was completed with two bipolar tined leads positioned at the RA lateral wall and RV apex through the RSVC (Fig. 4). In patient 3, who already received a RV lead via persistent LSVC, an Attain SD Model 4189 was advanced to the CS via the anomalous vessel and positioned in the MCV after an unsuccessful search for other tributaries. Due to instability of the lead in this position, the 4189 lead was exchanged for a Model 2187, whose tapered distal end facilitated its stable placement. In patient 4, the CS lead had to be positioned from the intercostal vein due to the RA-CSO atresia. Because of its small diameter and a straight angulation, an Amplatz (Becton Dickinson Co., Franklin Lakes, NJ, USA) catheter for right coronary cannulation was advanced through an Attain LSD 6116 delivery system to cannulate the vessel. An angioplasty guidewire was then successfully advanced into the MCV. A model 4193 lead (Medtronic) was advanced over the guidewire, 194
Figure 3. Patients 1. The implantation was performed via the persistent LSVC, since no communication was present between the right and left SVCs. The LV lead was positioned in the MCV. LAO 35-degree projection. LAO = left anterior oblique; LSVC = left superior vena cava; LV = left ventricular; MCV = middle cardiac vein; SVC = superior vena cava.
though it could not reach the MCV because of the unusual angle at the junction between the innominate and left intercostal veins. Neither was it possible to position an Easy-Trak lead (Guidant Corp., Minneapolis, MN, USA) by the same maneuvers. The 4193 lead was finally positioned in the MCV through a multipurpose angiographic catheter. The implant was completed by positioning the RA and RV leads via the RSVC. Follow-Up At a median follow-up of 11 ± 4 months, no complications had occurred. Stable lead positions on chest roentgenograms and satisfactory pacing/sensing parameters were confirmed in all patients. Decreases in NYHA functional class and improvements in echocardiographic indexes of LV function were observed. Discussion The prevalence of persistent LSVC has been estimated to be 0.5% in otherwise normal hearts and 3–10% in the presence of other congenital abnormalities.3,4 Unless specifically searched for, the presence of a persistent LSVC may be overlooked, including on echocardiography.5 Therefore, implanting physicians are usually presented with an unexpected finding that requires the use of tools not readily available in the electrophysiological
January 2003, Part II
PACE, Vol. 26
BIVENTRICULAR PACING VIA LSVC
Figure 4. In patient 2 a small-bodied lead was preliminarily curved at the distal end and was used to explore the CS until a posterolateral branch (not visualized before) was entered. The implant was completed with two bipolar tined leads positioned at the RA lateral wall and the RV apex through the right SVC. (Panel A) RAO 25-degree projection. (Panel B) LAO 35-degree projection. CS = coronary sinus; LAO = left anterior oblique; RA = right atrial; RAO = right anterior oblique; RV = right ventricular; SVC = superior vena cava.
laboratory. This report provides useful information regarding how to handle such a finding. CS Angiography The suggested technique to achieve optimal lead positioning in a CS branch requires the initial visualization of the CS venous system by occlusive venography. Standard catheters with an inflated 10-mm balloon diameter are usually appropriate for this purpose. However, persistent LSVC frequently drains into an enlarged CS precluding the performance of an occlusive venogram. In presence of a giant CS, balloon catheters of larger diameters or catheters used in other settings, for instance percutaneous closure of interatrial defects, can be used to visualize the CS venous system. CS Exploration Various leads with different shapes, angles, and dimensions are needed to explore the CS and identify suitable tributaries. The leads used in the patients offered advantages. In three cases the MCV, and in one a posterolateral tributary were PACE, Vol. 26
engaged. Both tributaries were large vessels. However, their engagement via downstream, instead of upstream catheterization from the RA, requires lead manipulations at sharp angles. In a recent report, Lyon and Kappenberger6 have described their failure to reach a posterolateral vein via downstream catheterization of the CS with a 10512 lead (Medtronic). In that case, the presence of an innominate vein allowed the lead to be eventually positioned in the CS tributary via the RA. The experience in the present study shows that the availability of appropriate leads allows the successful penetration of tributaries entering the CS at tight angles. This is particularly important in approximately 30% of cases of persistent LSVC where an innominate vein cannot be found between the two superior venae cavae, as in patients 1 and 3).4,7,8 Single Side Approach It may be argued that, in patients with no communication between the RSVC and subclavian vein, the leads could have been placed from the right side. However, the lead placement from the
January 2003, Part II
195
GASPARINI, ET AL.
left side via the persistent LSVC does not expose the patient to the additional risk of right subclavian vein puncture.
at intermediate follow-up, signs of clinical and echocardiographic improvements were observed despite placement of the LV leads in the MCV.
Effectiveness of LV Stimulation Placement of leads for LV stimulation in lateral or posterolateral CS tributaries may offer better cardiac resynchronization, though this was possible only in patient 3. In the other three patients, neither a posterolateral tributary nor even the great cardiac vein could be entered after meticulous dragging of the lead along the CS walls, forcing placement of the lead in the MCV. Nonetheless,
Conclusions The experience gained from these four cases of persistent LSVC shows that the direct lead placement in large CS tributaries, like the MCV or posterolateral vein, is feasible and safe provided that leads with adequately angled tips are used. Successful LV stimulation can be accomplished, which, in turn, resynchronizes cardiac contraction with its expected advantages.
References 1.
Cazeau S, Leclercq C, Lavergne T, et al. Effects of multisite biventricular pacing in patients with heart failure ad intraventricular conduction delay. N Engl J Med 2001; 344:873–880. 2. Leclerq C, Kass DA. Retiming the failing heart: Principles and current clinical status of cardiac resynchronization. J Am Coll Cardiol 2002; 39:194–201. 3. Nsah EN, Moore GW, Hutchins GM. Pathogenesis of persistent left superior vena cava with a coronary sinus connection. Pediatr Pathol 1991; 11:261–269. 4. Campbell M, Deuchar DC. The left-sided superior vena cava. Br Heart J 1954; 16:426–439. 5. Zellers TM, Hagler DG, Julsrud PR. Accuracy of two-dimensional
196
echocardiography in diagnosing left superior vena cava. J Am Soc Echocardiogr 1989; 2:132–138. 6. Lyon X, Kappenberger L. Implantation of a cardiac resynchronization system for idiopathic dilated cardiomyopathy in a patient with persistent left superior vena cava using an experimental lead for left ventricular stimulation. PACE 2000; 23:1439–1441. 7. Lennox CC, Zuberbuhler JR, Park SC, et al. Absent right superior vena cava with persistent left superior vena cava: Implications and management. Am J Cardiol 1980; 45:117–122. 8. Birnie D, Tang ASL. Permanent pacing from a left ventricular vein in a patient with persistent left and absent right superior vena cava. PACE 2000; 23:2135–2137.
January 2003, Part II
PACE, Vol. 26
