VDD pacing from the middle cardiac vein via a persistent left superior vena cava

We report a combination of unusual features demonstrating a permanent pacemaker implantation of a single-pass VDD lead by way of an anomalous persistent left superior vena cava in the middle cardiac vein. The ventricular stimulation resembled a right bundle branch block QRS morphology and was successfully synchronized by spontaneous atrial activity. This case illustrates an alternative approach of effective VDD pacing and sensing in patients with such a venous anomaly when other standard implantation sites fail.