Problems encountered during insertion of permanent endocardial pacing electrode

Subclavian vein anatomic subtypes defined by digital cinefluroscopic venography prior to permanent pacemaker lead insertion

Digital cinefluoroscopic venography of the subclavian vein was performed in 26 consecutive patients. The optimal stored image of the anticipated venipuncture site was magnified, road mapped, and used to compare with fluoroscopic-guided venipuncture. Two anatomic subtypes for both subclavian veins were observed. For the left subclavian vein, a gradual curve was seen most often (57%), while the remainder (43%) exhibited an "s"-shaped curve. For the right subclavian, a gradual curve was observed most frequently (60%) while an acute 90 degrees angle was noted in the remainder (40%). The "s"-shaped curve in the left subclavian vein necessitated redirection of the needle site both laterally and cranially. In three or 12% of patients venography showed either subclavian thrombosis or a persistent left superior vena cava and lead insertion was moved to the opposite side. Successful venipuncture and subsequent cannulation of the subclavian vein was achieved with the first or second passage of the needle in 22 or 85% of the 26 patients. Digital cinefluoroscopic venography appears to be both safe and rapid and may facilitate insertion of permanent pacemaker leads into the subclavian vein.

Pacemaker electrode implantation in patients with persistent left superior vena cava

Four out of 661 consecutive patients with permanent endocardial VVI pacing had the pacing lead introduced through a persistent left superior vena cava. It was difficult to introduce the lead from the right atrium into the right ventricle because the tip of the lead tended to be deflected away from the tricuspid orifice. This difficulty was overcome by shaping the lead into a pigtail with 3-4 cm wide loop. This avoided the risk of entering a branch of the coronary sinus in order to reach the right atrium. This technique made it easier to position the lead in the right ventricular apex. There were no complications in these four patients during a mean follow up of three years.

Implantation of a dual chamber pacemaker in a patient with persistent left superior vena cava

A patient underwent dual chamber pacemaker implantation by puncture of the left subclavian vein. During the procedure we observed persistence of the left superior vena cava. A "J-shaped" atrial lead was used for ventricular pacing with excellent long-term results. This technique can be a valuable alternative when confronted with the problem of persistent left superior vena cava during pacemaker implantation.

Endocardial pacing in a patient with sinus node dysfunction and absent right superior vena cava

A patient with sinus node dysfunction and absent right superior vena cava underwent stable temporary and permanent endocardial pacing via a left sided superior vena cava. Active fixation of the electrode and epicardial pacing were not necessary.