Persistence of the left superior vena cava is rare, being found in 0.3–2% of the general population, and shows considerable anatomical variability. We report the case of a 64-year-old man with idiopathic dilated cardiomyopathy, admitted electively for implantation of a cardiac resynchronization therapy defibrillator. Access was achieved via the left cephalic vein, but the lead was seen to advance to the left of the spinal column. Contrast injection revealed a persistent left superior vena cava draining into the right atrium close to the coronary sinus ostium.

On encountering this congenital defect, many operators immediately decide to use special techniques, particularly for biventricular devices; some adopt a right approach to facilitate catheter manipulation, others use a hybrid technique (right and left in the same procedure), and some implant the right ventricular lead in the left ventricle. However, these techniques can be rather complex and carry an increased risk of infection and vascular injury, especially with a bilateral approach. Therefore, since according to various authors and our own experience conventional implantation can be safe and effective, it was decided to attempt this approach first. All the leads were positioned by the conventional technique, including a quadripolar lead in the coronary sinus (Figure 1).

Figure 1.

Chest X-ray immediately after implantation of a cardiac resynchronization therapy defibrillator through a persistent left superior vena cava.

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At three-month follow-up stimulation thresholds were satisfactory and effective resynchronization had been achieved. In conclusion, although persistence of the left superior vena cava hampers implantation, the simplest approach should be attempted first.