Case 1
We present the case of a 70-year-old man with a history of chronic coronary syndrome, who was admitted due to recurrent syncope. The ECG showed sinus rhythm with right bundle branch block. A cardiac magnetic resonance imaging was requested, which reported a dilated cardiomyopathy of ischemic origin with moderate ventricular dysfunction. As an incidental finding, a PLSVC with agenesis of RSVC was observed, draining into a dilated coronary sinus (CS). Therefore, an implantable cardioverter-defibrillator (ICD) was indicated. Due to the absence of RSVC, left axillary vein puncture was performed without incident. Several attempts were made to introduce the ICD lead into the RV apex through different modifications of the curve of the stylet; however, it was repeatedly directed towards the RV outflow tract possibly due to coil stiffness. Finally, we decided to use a Selectra 3D 65cm sheath (Biotronik, SE&Co), commonly used for left bundle branch area pacing. With a 0.375mm guidewire, we reached the right atrium (RA) through the CS, and then we advanced the sheath through it. Once in RA, by counter-clockwise rotation, we were able to orient the tip of the sheath towards the tricuspid valve (TV) and cross into the RV without difficulty. We subsequently removed the guidewire and advanced a Durata 7122-Q 65cm lead (Abbott Medical S.A.) up to the RV apex. After confirming adequate detection and stimulation parameters, the sheath was removed using the usual peel-away technique. The lead in RA was placed in the right appendage, without requiring the use of a sheath. All parameters remained stable during follow-up, with no complications (Figure 1).