Background: Persistent left superior vena cava is the most common thoracic venous anomaly. It is usually asymptomatic, but it can make it difficult to implant intracardiac devices . Case presentation: We present a novel technique to facilitate right ventricular lead implantation in two patients with persistent left superior vena cava and the absence of the right superior vena cava. We used a fixed-curve Selectra 3D sheath (Biotronik), orienting the sheath towards the tricuspid valve by rotating it in a counter-clockwise direction. During follow-up, the electrodes remained stable. Discussion: Our technique was safe, simple and feasible for patients with this complex venous anatomy.

New therapeutic possibilities open up in the nonpharmacological rate control of patients with atrial fibrillation, and an approach with an ablation line around the AVN could be useful both for modulating the ventricular response and for safer AV ablation if this is finally required.