A 71-year-old woman with idiopathic cardiomyopathy and permanent atrial fibrillation for several years.
The patient developed heart failure with functional capacity III (NYHA) despite adequate medical treatment.
The echocardiogram showed moderate left ventricular dilatation (LVEDD 64 mm), severe impairment of left ventricular systolic function (FE 30%) and significant dilatation of the left atrium (diameter 56 mm).
The treating cardiologist referred her to our institution for biventricular repair.
The implant was planned with usual approach on the left side.
A left prepectoral subcutaneous pocket was made and puncture of the left axillary vein was performed with Seldinger technique, without incidents.
As the guidewire advanced, an unusual presentation was observed from the left subclavian vein to the inferior vena cava, compatible with the presence of a PLSVC.
A venogram confirmed the diagnosis of PLSVC, with no communication with the right superior vena cava system.
The venogram also corroborated the drainage of the PLSVC to the right atrium through the coronary sinus, without intracardiac shunt.
Then, an active fixation ventricular electrode Medtronic® model 4076 was advanced through the coronary sinus to the right atrium, directing it through the tricuspid valve to the right ventricular septum infundibum.
A sensitive R wave of 12.6 mV was obtained, with a right ventricular stimulation threshold of 0.4 V to 0.5 ms, with stimulation impedance of 550 Ohms.
Subsequently, using a Ber-mann catheter with orifices proximal to the balloon, contrast medium injection was performed from the medial portion of the coronary sinus, showing a dilated coronary sinus, without contrasting the lateral branches of the coronary veins.
Then, using a long sheath and a Medtronic® guide catheter 130° angle (model 6248 of 130) a left posterolateral coronary vein was cannulated with a left ventricular pacing threshold of 1.096 m.
Both electrodes were attached to the prepectoral fascia and connected to the respective ports of the Medtronic® Insync III generator model 8042, occluding the auricular port.
Finally, the procedure was completed by fulgurating the compact AV node.
The patient achieved satisfactory recovery and functional capacity.
After 15 days, the device was controlled, which confirmed 99% biventricular pacing.
An R wave of 11.2 -15.68 mV was measured in the right ventricle, with a right ventricular stimulation threshold below 0.5 V to 0.4 ms with an impedance of 430 Ohms.
The left ventricular R wave was greater than 22.4 mV, the stimulation threshold was 1.5 V to 0.4 ms and the impedance was 776 Ohms.
After 10 months of follow-up, the patient remained under regular control with his cardiologist and was in functional capacity I-II (NYHA).
The last control of its device showed 99% biventricular stimulation and the parameters of sensation and stimulation of both electrodes are adequate.
The right ventricular electrode sense R wave over 8.0 mV has a stimulation threshold of 1.0 V to 0.4 ms, with impedance of 480 Ohms.
The left ventricular electrode misses an R wave of 12.0 mV, has a stimulation threshold of 1.5 V to 0.4 ms, with impedance of 971 Ohms.
He maintains complete atrioventricular block with nodal leakage at 44 beats per minute.
