Discussion
The presence of PLSVC associated with the absence of RSVC is rare, and its appearance is related to alterations in the development of the venous system during pregnancy6. It is usually asymptomatic but may complicate the implantation of intracardiac devices. The main problem is the presence of an acute angle between the CS ostium and the TV, preventing adequate orientation of the lead towards the RV7. This is partially resolved by right venous access through the RSVC. However, in patients with no RSVC in whom the RV cannot be accessed by left venous access, an epicardial approach and subsequent tunnelling should be used5. To avoid epicardial access and facilitate implantation, several methods have been proposed. The most common technique consists of curving the stylets at different angles8. However, it is not always effective as it requires considerable operator experience and skill, in addition to the risk of RA perforation with electrode manipulation7. Subsequently, two alternative methods have been described, using a sheath for CS cannulation during cardiac resynchronization therapy9, or a Medtronic C315-S10 sheath frequently used for implantation of leads in the area of His or the left bundle branch area7, allowing both to orient and advance the electrodes towards the RV apex.
We present two patients diagnosed with PLSVC and the absence of RSVC who required the implantation of an intracardiac device. In both, a novel technique was used, involving the use of Selectra 3D sheath (Biotronik, SE&Co) to facilitate the advancement of the lead to the RV by performing a counter-clockwise rotation. In addition, in one of the cases, lead implantation was achieved in the left bundle branch area, with adequate electrocardiographic and pacing parameters that were maintained at follow-up.
This paper presents the initial report on the use of this sheath and the insertion of a lead in the left bundle branch area in patients with PLSVC. This is a safe and easy technique to perform, and we consider it an option to be considered in patients with complex venous anatomy, saving procedural and fluoroscopy time.