Optimal technique for right ventricular lead implantation in isolated persistent left superior vena cava

A 75-year-old male presenting with multiple syncoptic episodes was diagnosed with sick sinus syndrome and referred for permanent pacemaker implantation. Venous access through the left subclavian vein revealed the presence of persistent left superior vena cava (PLSVC). Additionally, right subclavian venous system venography demonstrated the absence of SVC on the right side, confirming the diagnosis of isolated PLSVC. Α long (65 cm) ventricular lead was subsequently introduced through the left SVC and the coronary sinus (CS) to the right atrium, and afterwards further advanced to the hepatic vein. Next, the lead was retracted back to the right atrium, while the stylet was slightly withdrawn resulting in angulation of the lead tip. The curved lead was then advanced towards the tricuspid valve, easily crossing the tricuspid orifice and was, eventually, actively affixed on the ventricular wall. Subsequently, a right screw-in 58 cm lead was introduced through the CS and implanted in the right atrial appendage. Post-procedurally, pacemaker sensing and pacing were appropriate. Echocardiography did not show additional congenital malformations.