Case report
Utilisation of the snare technique for left ventricular lead placement in a patient with persistent left superior vena cava
Utilização da técnica de snare para implantação de életrodo ventricular em doente com veia cava superior esquerda persistente
Gustavo Lima da Silva
, João de Sousa, Pedro Marques
Corresponding author
Serviço de Cardiologia, Hospital de Santa Maria, Centro Académico Médico de Lisboa, CCUL, Lisboa, Portugal
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Pre-treatment. The white arrow points out the aneurysm's neck area. B) Final angiographic result. C) Initial IVUS LCx imaging study. D) Initial OCT LCx imaging pullback. E) Final IVUS LCx imaging pullback. F) Final OCT LCx imaging pullback.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Iván J. Núñez-Gil, Pedro Marcos Alberca, Nieves Gonzalo, Luis Nombela-Franco, Pablo Salinas, Antonio Fernández-Ortiz" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Iván J." "apellidos" => "Núñez-Gil" ] 1 => array:2 [ "nombre" => "Pedro Marcos" "apellidos" => "Alberca" ] 2 => array:2 [ "nombre" => "Nieves" "apellidos" => "Gonzalo" ] 3 => array:2 [ "nombre" => "Luis" "apellidos" => "Nombela-Franco" ] 4 => array:2 [ "nombre" => "Pablo" "apellidos" => "Salinas" ] 5 => array:2 [ "nombre" => "Antonio" "apellidos" => "Fernández-Ortiz" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918300540?idApp=UINPBA00004E" "url" => "/21742049/0000003700000002/v1_201803200458/S2174204918300540/v1_201803200458/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2174204918300114" "issn" => "21742049" "doi" => "10.1016/j.repce.2017.11.016" "estado" => "S300" "fechaPublicacion" => "2018-02-01" "aid" => "1121" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "rev" "cita" => "Rev Port Cardiol. 2018;37:179-99" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3514 "formatos" => array:3 [ "EPUB" => 126 "HTML" => 2796 "PDF" => 592 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review Article</span>" "titulo" => "Cardiac channelopathies: The role of sodium channel mutations" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "179" "paginaFinal" => "199" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Canalopatias cardíacas: o papel das mutações nos canais de sódio" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 3519 "Ancho" => 3000 "Tamanyo" => 641314 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Diagnostic algorithm for Brugada syndrome. There are three patterns of electrocardiographic abnormalities in the right precordial leads (V1-V3). Type 1 is considered to be diagnostic, unlike types 2 and 3 (in presence of which provocation tests with SCB must be performed). Other electrocardiographic abnormalities that may be present in BrS are: prolongation of the PR interval and right branch block. A definitive diagnosis is made in presence of type 1 ST-segment elevation in at least one V1-V3 lead and when one of the clinical criteria presented in the figure is met. AMI: acute myocardial infarction; ANS: autonomic nervous system; C/ARVD: cardiomyopathy/arrhythmogenic right ventricular dysplasia; CCB: calcium channel blockers; CNS: central nervous system; ECG: electrocardiogram; LVH: left ventricular hypertrophy; PTE: pulmonary thromboembolism; RV: right ventricle; RVOT: right ventricular outflow tract; SCB: sodium channel blockers; SSRIs: selective serotonin reuptake inhibitors; VF: ventricular fibrillation; VT: ventricular tachycardia; β-blockers: beta blockers. *May unmask genetic susceptibility to BrS.</p> <p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Extracted and adapted from Berne and Brugada (2012).<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">51</span></a></p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Diana João Fonseca, Manuel Joaquim Vaz da Silva" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Diana João" "apellidos" => "Fonseca" ] 1 => array:2 [ "nombre" => "Manuel Joaquim" "apellidos" => "Vaz da Silva" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S0870255117302688" "doi" => "10.1016/j.repc.2017.11.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117302688?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918300114?idApp=UINPBA00004E" "url" => "/21742049/0000003700000002/v1_201803200458/S2174204918300114/v1_201803200458/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Utilisation of the snare technique for left ventricular lead placement in a patient with persistent left superior vena cava" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "201.e1" "paginaFinal" => "201.e3" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Gustavo Lima da Silva, João de Sousa, Pedro Marques" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Gustavo" "apellidos" => "Lima da Silva" "email" => array:1 [ 0 => "gustavolssilva@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "João" "apellidos" => "de Sousa" ] 2 => array:2 [ "nombre" => "Pedro" "apellidos" => "Marques" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital de Santa Maria, Centro Académico Médico de Lisboa, CCUL, Lisboa, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Utilização da técnica de <span class="elsevierStyleItalic">snare</span> para implantação de életrodo ventricular em doente com veia cava superior esquerda persistente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1005 "Ancho" => 2000 "Tamanyo" => 100056 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A, B) Venography in posterior-anterior view.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Persistence of the left superior vena cava (PLSVC) occurs in about 0.3-0.7% of the general population. It is an anatomic variant of particular importance in patients who need cardiac resynchronisation therapy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 77-year-old male with ischaemic heart disease, on ambulatory NYHA IV, depressed left ventricular (LV) function (ejection fraction of 20%) and left bundle branch block (QRS width of 170 msecs), on optimised medical therapy. PLSVC was identified during an attempted left-sided CRT-D implantation at another institution. Cardiac magnetic resonance confirmed the diagnosis of PLSVC with anastomosis to the coronary sinus (CS) ostium. Right-sided CRT-D implantation was then performed with successful placement of the right atrium and right ventricular apical defibrillator leads, although with LV lead implantation failure. The patient was therefore referred to our department for LV lead placement.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The left subclavian vein (LSV) was punctured for percutaneous sheath insertion. The sheath was advanced through the PLSVC to the CS and venography was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A and B), followed by selective cannulation of the posterior cardiac vein (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>, black arrow). A guide wire (Acuity Whisper<span class="elsevierStyleSup">®</span>, Boston Scientific, Inc.) was introduced and advanced through the anterior collateral veins and the anastomotic vein directly back to the PLSVC (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>, white arrow). A snare system (En Snare 30<span class="elsevierStyleSup">®</span>, Merit Medical Systems, Inc.) was introduced through a second sheath via the LSV up to the PLSVC (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>, black arrow), and the distal end of the guidewire was gradually pulled towards the skin surface. Both ends of the guidewire were under the operator's control. The LV lead was advanced in an antidromic fashion through the guidewire to the anterolateral position (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A and B). The LV lead pacing threshold was 0.8 V at 0.5 msec. The LV lead was subsequently tunnelled (Lead-extension Accessory kit, Medtronic) subcutaneously to reach the right pocket and was connected to the previously implanted generator. No complications occurred.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion and conclusion</span><p id="par0020" class="elsevierStylePara elsevierViewall">There are previous case reports of CS and LV tributaries cannulation via the right subclavian vein in patients with PLSVC. However, this patient had been subjected to a prior unsuccessful right-sided LV lead implantation procedure. The most common causes of failure are tumultuous flow in the CS ostium and impossibility to use balloon occlusion catheters in a giant CS.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">LV lead implantation through a left-sided approach in PLSVC is feasible but technically challenging. The use of a snare system to assist the placement of the LV lead was chosen due to the presence of small vessels (collaterals) in the posterolateral area with adequately sized vessels in the lateral area. The snare technique has been described in patients where delivery of the LV lead to the target vessel cannot be obtained with the standard approach. It is a safe technique and it reduces percutaneous implant failure and the subsequent need for a surgical approach.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">2,3</span></a> However, its use in patients with anatomical variants such as PLSVC had not been previously described.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The snare system is a useful new tool for LV lead implantation in patients with PLSVC and an adequate venous collateral anatomy.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1005673" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec965459" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1005672" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec965460" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion and conclusion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-07-19" "fechaAceptado" => "2017-01-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec965459" "palabras" => array:3 [ 0 => "Persistence of the left superior vena cava" 1 => "Cardiac resynchronisation therapy" 2 => "Snare technique" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec965460" "palabras" => array:3 [ 0 => "Veia cava superior esquerda persistente" 1 => "Ressincronização cardíaca" 2 => "Técnica <span class="elsevierStyleItalic">snare</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Persistence of the left superior vena cava occurs in about 0.3-0.7% of the general population. It is of particular importance in patients who need cardiac resynchronisation therapy. We present a unique case in which a snare system and tunnelling tool were used to place the left ventricular lead in a patient with persistence of the left superior vena cava.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A veia cava superior esquerda persistente ocorre em 0,3-0,7% da população geral e é de particular importância em doentes que necessitam de terapêutica de ressincronização cardíaca. Apresentamos um caso único onde foram usados um sistema de <span class="elsevierStyleItalic">snare</span> e tunelizador para a implantação do elétrodo esquerdo num doente com veia cava superior esquerda persistente.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1005 "Ancho" => 2000 "Tamanyo" => 100056 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A, B) Venography in posterior-anterior view.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1249 "Ancho" => 1200 "Tamanyo" => 102037 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Snare technique: Selective cannulation of the posterior cardiac vein (black arrow). Guidewire advanced through the anterior collateral veins and anastomotic vein directly back to the PLSVC (white arrow). Snare system introduced through a second sheath via the LSV up to the PLSVC (black arrow). LSV: left subclavian vein; PLSVC: persistence of the left superior vena cava.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 999 "Ancho" => 2000 "Tamanyo" => 108620 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Left ventricle lead final position: (A) Right anterior oblique view; (B) Left anterior oblique view.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hybrid right-left cardiac resynchronization therapy defibrillator implantation in persistent left superior vena cava" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Anselmino" 1 => "M.C. Marocco" 2 => "C. Amellone" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/europace/eun371" "Revista" => array:6 [ "tituloSerie" => "Europace" "fecha" => "2009" "volumen" => "11" "paginaInicial" => "533" "paginaFinal" => "534" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19112072" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful implantation of a left ventricular lead for cardiac resynchronization therapy in extremely unfavourable coronary venous anatomy: “over the wire” technique" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "W. Kranig" 1 => "R. Grove" 2 => "G. Lüdorff" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Herzschrittmacherther Elektrophysiol" "fecha" => "2004" "volumen" => "32" "paginaInicial" => "211" "paginaFinal" => "217" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Goose neck snare for LV lead placement in difficult venous anatomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.J. Worley" 1 => "D.C. Gohn" 2 => "R.W. Pulliam" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1540-8159.2009.02573.x" "Revista" => array:6 [ "tituloSerie" => "Pacing Clin Electrophysiol" "fecha" => "2009" "volumen" => "32" "paginaInicial" => "1577" "paginaFinal" => "1581" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19821941" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003700000002/v1_201803200458/S2174204918300552/v1_201803200458/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003700000002/v1_201803200458/S2174204918300552/v1_201803200458/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918300552?idApp=UINPBA00004E" ]
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| 2020 November | 48 | 19 | 67 |
| 2020 October | 33 | 16 | 49 |
| 2020 September | 92 | 14 | 106 |
| 2020 August | 40 | 20 | 60 |
| 2020 July | 59 | 11 | 70 |
| 2020 June | 52 | 13 | 65 |
| 2020 May | 32 | 12 | 44 |
| 2020 April | 34 | 18 | 52 |
| 2020 March | 72 | 19 | 91 |
| 2020 February | 98 | 10 | 108 |
| 2020 January | 45 | 7 | 52 |
| 2019 December | 37 | 8 | 45 |
| 2019 November | 26 | 10 | 36 |
| 2019 October | 54 | 7 | 61 |
| 2019 September | 48 | 8 | 56 |
| 2019 August | 29 | 8 | 37 |
| 2019 July | 41 | 8 | 49 |
| 2019 June | 35 | 16 | 51 |
| 2019 May | 42 | 3 | 45 |
| 2019 April | 21 | 17 | 38 |
| 2019 March | 40 | 15 | 55 |
| 2019 February | 62 | 5 | 67 |
| 2019 January | 32 | 11 | 43 |
| 2018 December | 34 | 11 | 45 |
| 2018 November | 81 | 20 | 101 |
| 2018 October | 61 | 16 | 77 |
| 2018 September | 28 | 11 | 39 |
| 2018 August | 24 | 7 | 31 |
| 2018 July | 22 | 4 | 26 |
| 2018 June | 30 | 5 | 35 |
| 2018 May | 24 | 6 | 30 |
| 2018 April | 79 | 12 | 91 |
| 2018 March | 47 | 11 | 58 |
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