Transvenous defibrillator implantation in patients with persistent left superior vena cava and right superior vena cava atresia

In this report a transvenous cardioverter defibrillator implantationis described in two patients with a persistent left-sided superiorvena cava and right SVC atresia. In the first case, manoeuvringof the guide wire inserted through the left subclavian veininto the SVC proved impossible, revealing a left SVC originatingfrom the left brachiocephalic vein with an acute corner. Changingthe side of implantation and inserting a CPI Endotak catheterthrough the right subclavian vein, the lead was easily advancedthrough the left SVC into the coronary sinus and then into theright atrium with the tip abutting the lateral atrial wall.Subsequent manoeuvres allowed passage of the tip of the catheterinto the right ventricular apex with the proximal defibrillationcoil of the Endotak lead in the low left SVC, with its distallimit at the junction with the coronary sinus. A biphasic waveformsingle pathway RVleft SVC successfully defibrillated with astored energy of 5 J. In the second patient, implantation of a transvenous Medtronicsystem was possible from a left infraclavicular approach. Atripolar R V coil was inserted into the right ventricle viathe persistent left SVC and contiguous coronary sinus. Becauseof the acute angle required to enter the R V in this secondcase, the R V lead was looped in the right atrium in order toenter the RV in a satisfactory, albeit atypical RV location.This patient was successfully defibrillated with a 5 J monophasicwaveform delivered between the RV coil, a CSIleft SVC coil,and a subcutaneous patch. In conclusion, both of these patients illustrate the abilityto use transvenous ICDs successfully in patients with persistentleft superior vena cava although the implantation techniquedeviates substantially from traditional methods.