Persistent left superior vena cava (PLSVC) is a rare congenital anomaly that may complicate cardiac procedures when associated with a dilated coronary sinus (CS) and conduction disturbances. We report the case of a 27-year-old male with Wilson’s disease who presented with complete heart block. Echocardiography showed biatrial enlargement and severe CS dilation, while contrast-enhanced computed tomography (CT) confirmed PLSVC draining into the CS without a bridging vein. Anatomical constraints prevented cardiac resynchronization therapy, and dual-chamber pacemaker implantation proved technically challenging due to lead placement difficulties. This case highlights the importance of thorough preoperative assessment and individualized pacing strategies in patients with PLSVC, in order to anticipate anatomical challenges and optimize outcomes.