Heart 2011;-:1. doi:10.1136/heartjnl-2011-300145 REFERENCES

Dual-chamber pacemaker in persistent left superior vena cava An 84-year-old woman presented with pre-syncope. Her initial resting 12-lead ECG revealed sinus bradycardia and subsequent ECG revealed complete heart block associated with symptoms; she therefore underwent implantation of a dual-chamber permanent pacemaker. Implantation was performed using the left deltopectoral groove approach via the left cephalic vein. It was noted that a guidewire passed vertically down the left side of the cardiac border, suggesting a persistent left-sided superior vena cava (PLSVC). A venogram was performed, which confirmed the PLSVC draining into the coronary sinus and then right atrium. A 58 cm active fixation lead (Medtronic 4076, Minneapolis, USA) was placed via the coronary sinus into the right atrium and fixed at the right atrial free wall with excellent pacing data. A second active fixation lead of longer length (65 cm Medtronic 5076, Minneapolis, USA) was placed into the right atrium. The stylet was curved and the lead was looped in the right atrium and made to prolapse across the tricuspid valve and into the right ventricular apex and fixed there with excellent pacing data (panel A and B). PLSVC is a rare venous anomaly that is present in 0.3e0.5 % of the general population and is usually found incidentally during invasive procedures.1 2 It may cause difficulty in the placement of transvenous pacing leads due to the presence of multiple bends that need to be negotiated. The use of long active fixation leads for the right ventricle using a curved stylet may help in overcoming this technical difficulty