PMC8565685_01
ECG shows atrial fibrillation with complete atrioventricular block with an escape rhythm of 42/min, narrow QRS and normal QRS axis (30 degrees).
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ECG reveals atrial fibrillation with complete atrioventricular block with junctional escape approx. 42bpm (Figure 1).
Transthoracic echocardiogram: parasternal long axis (A), and modified short axis view (B) illustrating a dilated coronary sinus (yellow arrow)
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Absence of pericardial effusion and intracavitary formations as well as structural abnormalities. A dilated coronary sinus raised the suspicion of PLSVC (Figure 2).
A. After the lead introduction in the right subclavian vein, it takes an abnormal trajectory to the left side of the spine. B. The second image shows the point of the electrode exit through the coronary sinus in the right atrium. C. The third image shows the final position of the right ventricular lead on the interventricular septum after crossing the tricuspid annulus
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After we find out the right cephalic vein and advancing the guidewire with an abnormal path along the left edge of the cardiac silhouette, and not on the right-side as we would have expected in the case of the normal superior vena cava (Figure 3). Under fluoroscopy, with considerable procedural time, approximative 18 minutes (in patients with normal anatomy, mean fluoroscopy time in our lab for a VVI pacemaker implantation is no more than 2.5 minutes), it was possible to cross the tricuspid annulus and place a 58 cm bipolar lead of pace and sense with active fixation at the interventricular septum (Figure 3) with very good pacing parameters: RV sensing 13 mV, impedance - 690 Ohm, pacing threshold 0.5 V, with a duration of the stimulus of 0.4ms.