Left bundle branch pacing through direct puncture of superior vena cava

A 71-year-old man on haemodialysis over 2  years for chronic renal dysfunction needed pacemaker for paroxysmal atrial fibrillation and intermittent third-degree atrioventricular block with a long PR interval. Echocardiography illustrated decreased left ventricular ejection fraction. Left bundle branch pacing (LBBP) from the right subclavi an vein was planned considering the left cephalic vein-radial artery fistula. However, procedural angiography revealed the right subclavian vein and right internal jugular vein occlusion which failed to be opened after repeated attempts. Leadless pacing was not available at that time in China. After team discussion, we decided to directly puncture the superior vena cava (SVC) path instead of left subclavian vein path in consideration of reducing the risk of haemodialysis vascular access occlusion caused by leads. A wire was placed through the inferior vena cava as a guide for puncturing the SV C from right supraclavicular fossa, while posterior anterior and left lateral positions were used to determine the puncture direction and depth under fluoroscopy. We selected 4F-6F-8F vascular sheaths for sequence expansion and exchanged the wire (Panel A). Remaining LBBP steps were completed as using left subclavian vein path. Screwed 3830 lead (Medtronic Inc, MN, USA) pacing electrical characteristics confirmed successful LBBP (Panel B).
Source: Europace - Category: Cardiology Source Type: research