case_images: PMC11770388_01
case_images: AP, anteroposterior; AVB, atrioventricular block; BiVp, biventricular pacing; CRT-P, ardiac resynchronization therapy pacemaker; CS, coronary sinus; LVEF, left ventricular ejection fraction; PICM, pacing-induced cardiomyopathy; PLSVC, persistent left superior vena cava; PM, pacemaker; RAO, right anterior oblique.
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case_images: A 79-year-old Japanese female underwent transvenous lead pacemaker implantation for complete atrioventricular block with normal left ventricular ejection function (LVEF) (Figure 1A) and venography during the procedure revealed PLSVC draining into dilated CS and right SVC without an innominate vein 8 years previously. Chest X-ray showed cardiac enlargement and pleural effusion (Figure 1B), echocardiography a severely deteriorated LVEF of 23% and desynchrony due to RV pacing. No lead dislodgement was observed on chest X-ray (Figure 1C and D), and the lead parameters remained within acceptable limits.
case_images: Chest X-ray images after pacemaker implantation (A), when heart failure developed 6 years later due to pacing-induced cardiomyopathy (B), and 6 months after cardiac resynchronization therapy pacemaker upgrade in frontal view (C) and lateral view (D). CS, coronary sinus; CRT-P, cardiac resynchronization therapy pacemaker; PLSVC, persistent left superior vena cava.
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case_images: CS (Figure 2A and B, Supplementary material online, Videos S1). Cardiac resynchronization therapy pacemaker upgrade and additional atrial lead placement were attempted with patient consent. Retrograde venography using an angiographic balloon catheter through a guiding catheter (Attain Command +SureValve  6250VIC; Medtronic plc, Dublin, Ireland) revealed an enlarged CS with a slightly contrasting lateral vein ostium at the anterior wall (Figure 2C, Supplementary material online, Videos S2), which was identified as the target vein.
case_images: (A and B) Venography before pacemaker implantation revealed a persistent left superior vena cava without an innominate vein and a faint contrast of the lateral venous ostium branching from the coronary sinus (dotted line). A temporary right ventricular lead was inserted via the right superior vena cava. (C) Retrograde coronary sinus venography during cardiac resynchronization therapy upgrade delineates the contours of the giant coronary sinus, persistent left superior vena cava, and the lateral venous ostium region (dotted line). AP, anteroposterior; CS, coronary sinus; CRT-P, cardiac resynchronization therapy pacemaker; PLSVC, persistent left superior vena cava.
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case_images: Selective insertion into the lateral vein using a subselection catheter (Attain Select  II + SureValve  6248VI-90, Medtronic) inside the guiding catheter was achieved, and contrast infusion revealed that the lateral vein was steeply tortuous (Figure 3A). Because of the giant CS, the risk of lead dislodgement was considered high; thus, an active fixation quadripolar lead (Attain Stability  Quad 4798, Medtronic) was selected and delivered over the guidewire (Figure 3B and C). The distal electrode crossed a strong flexure of the target vein but did not pass the subsequent stenosis (Figure 3D); thus, the proximal electrodes could not advance into the target vein and remained within the CS. The subselection catheter was pulled into the guiding catheter to expose the third and fourth electrodes and the side helix between them, and the helix was pressurized against the anterior wall using the distal end curve of the subselection catheter (Figure 3E and F).