This patient with a history of mechanical aortic valve replacement, New York Heart Association class III heart failure, 25% left ventricular ejection fraction, and a left bundle branch block with a QRS of 160 ms was addressed for implantation of a biventricular pacemaker.

A left-sided axillary vein puncture was performed, with the guide wire revealing a left-sided persistent superior vena cava (PLSVC) (Figure 14-1). Contrast injection did not reveal the presence of posterolateral tributaries of the coronary sinus. Because of this and the absence of an innominate vein, venous access was switched to the right side with retrograde cannulation of the coronary sinus (Figure 14-2). A balloon catheter was placed in the great cardiac vein and allowed visualization of a lateral vein that was suitable for lead implantation (Figure 14-3). A bipolar coronary sinus lead was implanted in the lateral vein over a 0.014-inch angioplasty guide wire (Figure 14-4). Right ventricular and atrial pacing leads were implanted, with final position of the leads shown in Figure 14-5.

PLSVC is the most frequent venous anomaly of the thorax and may be found in 0.4% of device patients.¹ It results from nonobliteration of the left anterior cardinal vein during embryogenesis, which otherwise becomes the ligament of Marshall.²

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