Unusual approach of a pacemaker electrode in a patient with a silent superior vena cava syndrome.

A man with a history of bilateral pectoral pocket infection and subsequent pacemaker implantation with a screw-in epicardial lead was referred because of increasing lead impedance. Venography revealed bilateral total occlusion of the subclavian and innominate veins with extensive collateral formation in this asymptomatic patient. Both internal jugular veins were also totally occluded. Because repeated pacemaker implantation using epicardial leads resulted in increasing lead impedance of the ventricular lead within 1 year after implant, an alternative approach was found using the superior caval vein with minimal invasive thoracotomy for single lead VDD pacing.