His-bundle Pacing as a Bailout Therapy for a Patient with Subclavian Stenosis and No Suitable Coronary Sinus Branch: A Double Whammy

We present an interesting case of an 88-year-old man who was referred to our arrhythmia service for an upgrade of his dual-chamber pacemaker to a biventricular pacemaker for right ventricular pacing–induced cardiomyopathy. The patient was found to have stenosis of the left subclavian vein. Here, we describe the approach used to perform venoplasty in this patient. After venoplasty of the left subclavian vein, the patient did not have suitable coronary venous anatomy for deployment of the coronary sinus lead. Subsequently, a His lead was implanted. We achieved significant narrowing of the QRS with good thresholds and other lead parameters. Through this case report, we seek to present our approach of venoplasty in patients with occluded venous access for either an upgrade or a de novo implant.