the paper presents the case of a 57-year - old female patient operated on in 2011 due to critically calcified aortic stenosis . the patient underwent a splenectomy , lymphadenectomy and radiotherapy ( co-60 radiation ) due to lennert lymphoma in 1978 . the patient suffered from chronic atrial fibrillation ( af ) and was operated on using extracorporeal circulation in 2011  the aortic valve was replaced with a mechanical ats cardiac valve prosthesis . in the postoperational period , a third - degree atrioventricular block occurred , which required constant stimulation with an external pacemaker . the implemented treatment with steroids did not relieve the atrioventricular block . a decision to implant a permanent pacemaker was taken on day 12 after the surgery . a total blood flow blockage in the brachiocephalic vein ( fig . 1a ) was found during the puncture of the left subclavian vein . during the course of puncturing the right subclavian vein , critical stenosis and tortuosity of the superior vena cava a decision was taken on the 14 day after the surgery to implant an epicardial screw - in lead into the right apex of the heart through mini - sternotomy in the lower part of the previous operation field . after the sight - inspected preparation of the area , a medtronic 5071 - 35 cm electrode was implanted ( fig . when the stimulation parameters had been examined ( which did not differ from the results obtained in the case of a traditional endocavitary screw - in lead ) , the lead wire was connected to the biotronik talos pacemaker placed in the left hypochondriac region . the results of the stimulation parameter control examination performed 12 months after the operation were satisfactory . the previously applied therapy with the use of radiation ( co-60 ) had probably contributed to the occlusion of both the left subclavian vein and the superior vena cava , which rendered the placement of a pacemaker in the typical manner impossible . the presently applied method has not frequently been used in adults , yet in this case , the stimulation of the right apex of the heart was completely satisfactory , since the patient suffered from chronic atrial fibrillation . the surgery requires only a relatively small incision ( 5 - 6 cm ) within the existing scar tissue . the aforementioned case , due to anatomical reasons , required the application of such a procedure , which seems futile particularly in patients who have experienced cardiac device - related infective endocarditis . other modes of implantation that have been described by several authors , e.g. through the azygos vein [ 1 , 2 ] , the inferior vena cava , a femoral vein and the iliac vein [ 4 , 5 ] , entail a potentially greater possibility of rupture or injury to the whole system . they also impose some restrictions on the physical activities of patients with a pacemaker implanted using these methods . since we are usually dealing with elderly people who require e.g. hemodialyses , this often entails an infection of the implanted system . the current rapid progress in low - invasive techniques makes it possible to implant complex stimulation systems via epicardial leads through left - side mini - sternotomy . opponents of epicardial stimulation claim that it is less physiological , increases the resistance of the implanted lead   and causes greater exhaustion of the pacemaker , even when steroid electrodes are used . results of a 5-year follow - up observation of 16 patients , whose electrical conduction system of the heart had to be prosthetized , are promising and will soon be published . reported that it was fully justified in some patients . placing a pacemaker in the pectoral region   or under the rectus abdominis muscle  as suggested by the authors of the present report  depends on the operator 's experience . the implantation of the screw - in epicardial lead is in some cases the method of choice , which provides efficient and constant heart stimulation . evidently , each individual case requires a detailed analysis and the applied method should , above all , help the patient and by no means do any harm to them .
the paper presents a case report of a patient with a superior vena cava occlusion and post - operational ( after the implantation of the aortic valve ) atrioventricular block , which required constant stimulation . 
 an epicardial vvi pacemaker was implanted through mini - sternotomy in the lower part of the previous operation field with very satisfactory stimulation parameters . 
 implantation of a screw - in epicardial lead is in some cases the method of choice , which provides efficient and constant heart stimulation .