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.