Europace Advance Access originally published online on April 28, 2006
Europace 2006 8(6):456-458; doi:10.1093/europace/eul039
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PACING/CRT
Occlusion of the coronary sinus: a complication of resynchronisation therapy for severe heart failure
1 Department of Cardiology, St Lucas Andreas Hospital, Amsterdam, J. Toorpstraat 164, 1061 AE Amsterdam, The, Netherlands; 2 Department of Cardiology, Medical Center Alkmaar, The, Netherlands
Manuscript submitted 15 December 2005. Accepted after revision 28 February 2006.
* Corresponding author. Tel: +31 20 5108911. E-mail address: w.g.devoogt{at}planet.nl
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Abstract |
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The finding of complete obstruction of the proximal coronary sinus after left ventricular (LV) lead extraction during LV lead replacement is uncommon. In our case, we used a large collateral branch of the middle cardiac vein as an alternative route to the postero-lateral region. We have termed this the ‘collateral approach’.
Key Words: Coronary sinus obstruction, Resynchronization theraphy, Left ventriculars lead, Heart failure
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Case report |
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An 81-year-old patient with heart failure, New York Heart Association class III, 10 years after an extensive anterior infarction, CABG, and aneurysmectomy had a biventricular pacemaker implanted in November 2001.
The ECG pre-implant showed a prolonged PR interval of 300 ms and a QRS complex of 150 ms duration with an LBBB-like pattern. The echocardiogram revealed severe LV dysfunction with an ejection fraction of 10% and dyssynchrony of the septal wall when compared with the contractile postero-lateral wall.
At implant, a Medtronic (Minneapolis, MN, USA) 4193-88 left ventricular (LV) lead was situated in a large postero-lateral vein (Figure 1A and B). Initial pacing threshold was 1.2 V at 0.5 ms pulse duration and the LV R-wave amplitude was 16.0 mV. The two other leads were routinely placed, respectively, in the right atrial appendage and right ventricular apex.
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During follow-up, a gradual increase in LV threshold was observed, and 12 months after implant, there was loss of capture. The patient was offered LV lead replacement.
Almost without any force, the LV lead was withdrawn from the postero-lateral vein and out of the coronary sinus. A new guiding catheter was introduced and coronary sinus angiography was performed. The angiogram showed complete obstruction of the proximal coronary sinus (Figure 2). A guide wire could be passed through the obstruction but attempts to slide the pacing lead over the guide wire were unsuccessful.
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The coronary sinus angiogram 1 year before at the first CRT-pacemaker implant showed a large middle cardiac vein with collateral-branches to the postero-lateral area. At LV lead replacement, a Medtronic 4193 lead, inserted over the guide wire, was placed in a large collateral branch from the middle cardiac vein towards the postero-lateral region. The acute threshold was 1.5 V at 0.5 ms pulse duration and an R-wave amplitude of 15.5 mV (Figure 3).
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In comparison with the initial implantation, the tip of the electrode was located in nearly the same place as the first implant. The surface 12-lead ECG of both locations were almost identical (Figure 4). Recovery was uneventful.
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Discussion |
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Ventricular resynchronization therapy has proved to be a valuable addition in patients with severe heart failure and a wide QRS complex. Clinical experience has shown that newer techniques, particularly the over the wire lead, enable selective and exact LV positioning in the coronary sinus in >90% of cases.1
–3
However, late loss of capture probably due to micro-dislocation or fibrosis at the electrode tip has been reported.2,3 New designs of lead shape and the use of steroid eluting electrodes are expected to address this problem.
An occluded coronary sinus during re-intervention is very uncommon.4,5 Balloon dilatation of the obstruction in the coronary sinus could be considered when there is no alternative vessel and location of choice available. Recently, van Gelder et al.6 described a successful implantation of a coronary sinus lead after dilating and stenting of a coronary vein stenosis.
However, in our case, we could use the middle cardiac vein as an alternative route to the postero-lateral region.
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References |
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[1] Auricchio A, Stellbrink C, Block M, et al. Effect of pacing chamber and atrioventricular delay on acute systolic function of paced patients with congestive heart failure. The pacing therapies for congestive heart failure study group. The Guidant congestive heart failure research group. Circulation 1999; 99: 2993–3001.[Medline]
[2] Walker S, Levy S, Rex S, et al. Initial United Kingdom experience with the use of permanent, biventricular pacemakers. Europace 2000; 2: 233–9.
[3] Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, Kocovic DZ, Packer M, Clavell AL, Hayes DL, Ellestad M, Messenger J. for the MIRACLE Study Group. Cardiac resynchronization in chronic heart failure. N Engl J Med 2002; 346: 1845–53.
[4] Hazan MB, Byrnes DA, Elmquist TH, Mazzara JT. Angiographic demonstration of coronary sinus thrombosis: a potential consequence of trauma to the coronary sinus. Cath Cardiovasc Diagn 1982; 8: 405–8.[Medline]
[5] Wang SY, Yeh SJ, Lin FC. Coronary sinus stenosis as a late complication of catheter ablation in the Wolf Parkinson White syndrome. Cath Cardiovasc Diagn 1997; 42: 70–2.[CrossRef][Medline]
[6] van Gelder BM, Meijer A, Basting P, Hendrix G, Bracke FA. Successful implantation of a coronary sinus lead after stenting of a coronary vein stenosis. Pacing Clin Electrophysiol 2003; 26: 1904–6.[CrossRef][Medline]
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