Figure 1. ECG showing Atrial fibrillation with several pacing spikes without ventricular capture and significative pauses. An escape ventricular complex is seen after a non-capture pacing spike, and a subsequent ventricular pacing depolarization occurred
The device interrogation showed that the threshold was >5V/ 0.5ms, and the device was programmed with an output of 7.5V/ 0.5ms to assure ventricular capture. The clinical case was discussed in heart team meeting, where due to the history of three previous heart surgeries with probable multiple and severe adhesions and fibrosis of mediastinum complicating the placement of an epicardial lead, it was decided to try an endocardial approach. Through a left subclavian access, the CS was canulated with an Extended Hook sheath (Medtronic, Attain Command) and a lateral tributary vein with a sub-selective sheath (Medtronic, Attain Select 90s). A quadripolar lead (Medtronic) was placed in the lateral vein of the CS (figure 2).