Case 2
A 51-year-old man with a history of mild rheumatic mitral stenosis was admitted to a secondary hospital due to a symptomatic third-degree atrioventricular block with an escape rhythm of 40 bpm. It was decided to implant a pacemaker; however, during the procedure the implanters presented difficulties in advancing the guidewire. Venography was performed, which evidenced a PLSVC with drainage in the CS, and absence of RSVC. Our centre was contacted after these findings. Left axillary venous access was performed, and due to our previous experience, a Selectra 3D 65cm sheath (Biotronik, SE&Co) was used from the beginning to facilitate the advancement of the lead to the RV. As in the previous case, we accessed RA through the CS and performed a counter-clockwise rotation to orient the sheath towards the TV and advance the guidewire through it. The baseline ECG showed a left bundle branch block, so we decided to pace the left bundle branch area. Using counter-clockwise rotation, we supported the sheath against the interventricular septum and inserted a Solia S60 electrode (Biotronik) in the usual way. To check the optimal position and depth of the lead, left and right anterior oblique projections were made after contrast injection. The RA electrode was implanted without difficulty in the right appendage. The values of impedance, threshold, and R-wave amplitude were verified during the procedure. The ECG after implantation showed QRS narrowing up to 140ms with a QR pattern in V1. During follow-up, the leads remained stable, with no complications (Figures 2 and 3).