Europace Advance Access originally published online on July 18, 2007
Europace 2007 9(10):878-879; doi:10.1093/europace/eum146
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CARDIAC RESYNCHRONISATION THERAPY
A novel technique for placement of coronary sinus pacing leads in cardiac resynchronization therapy
Department of Cardiology, Athens Euroclinic, 9 Athanassiadou Street, Athens 11521, Greece
Manuscript submitted 17 May 2007. Accepted after revision 22 June 2007.
* Corresponding author. Tel: +30 210 6416600; fax: +30 210 6416661. E-mail address: dkatritsis{at}euroclinic.gr/ dgkatr{at}otenet.gr
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Abstract |
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 Top Abstract |
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A new technique for the placement of left ventricular pacing leads in the tributaries of the coronary sinus (CS) is described. Antegrade visualization of the CS is accomplished by selective coronary angiography, and a hydrophilic 0.032 in. wire is advanced along the CS. This facilitates the advancement of a CS sheath over a multipurpose diagnostic catheter. A hydrophilic angioplasty wire is then utilized for the negotiation of the inferior left ventricular vein and successful placement of the left ventricular pacing lead.
Key Words: Coronary sinus, Left ventricular pacing, Resynchronization
Inability to cannulate the coronary sinus (CS) and/or to advance the pacing lead into one of its tributaries is mainly responsible for the reported unsuccessful implant rates of 5–13%. In certain patients with peculiar CS anatomy, the placement of an LV pacing lead may be very challenging. Recently, the use of magnetic navigation for the placement of a guide wire within the CS was advocated for difficult cases. This report presents a new technique for rapid cannulation of the CS and advancement of the LV pacing lead with minimum fluoroscopy and procedure time in cases where conventional techniques have been unsuccessful.
A 56-year-old lady with dilated cardiomyopathy, left ventricular ejection fraction 25%, and prolonged QRS (178 ms) was referred for resynchronization therapy. Despite prolonged efforts (over 30 min of fluoroscopy time), the CS could not be successfully cannulated with a steerable electrophysiology electrode. All three shapes (mp, mph, and h) of the Rapido Cut-away sheath (Guidant, St Paul, Minneapolis, USA) were tried without success. Left coronary angiography was performed using a 5F diagnostic 4L Judkins catheter (Cordis, Miami, FL, USA) through the femoral route. Digital acquisition of 12.5 frames/s was prolonged until full visualization of the coronary venous system was accomplished. There was a very high position of the CS ostium and a subsequent steep angle of the CS course in a way that manipulation and advancement of any lead were virtually impossible (Figure 1). A cine-angiogram that was obtained in the LAO 20 projection (Figure 1) allowed the orientation of the tip of a multipurpose Rapido sheath towards the high ostium of the CS. Thus, the ostium of the CS was engaged but further advancement of the sheath or a steerable electrophysiology electrode was impossible. A hydrophilic 0.032 in. J wire (Terumo, Tokyo, Japan) was then advanced through a 5F multipurpose catheter along the CS towards the great cardiac vein. The hydrophilic nature of this wire allowed easy negotiation of the CS lumen and provided support for the advancement of the 5F multipurpose catheter and consequently the CS sheath into the CS just below the ostium of the inferior LV vein. A PT2, LS (Boston Scientific, Miami, FL, USA) hydrophilic angioplasty guide wire was then advanced into the inferior LV vein, and the LV pacing lead was successfully introduced over it. Total fluoroscopy time was 3.5 min.
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The technique was subsequently tried in the next 10 patients who were subjected to resynchronization therapy. The same operator was involved in all cases. The average fluoroscopy time to successfully advance and position the LV lead was 4.5 ± 1.0 min. No complications were noted.
Our technique has two main advantages. First, it allows easy identification of the CS orifice and the selection of a suitable side branch for LV pacing. Secondly, it provides support for the safe advancement of the CS sheath up to the orifice of this side branch. In our laboratory, it is now routinely used in all difficult biventricular pacing cases, with considerable success and minimal radiation exposure. We advocate its use in all patients in whom CS cannulation is technically very demanding and results in a cumbersome procedure, thus justifying the extremely low but still not negligible risk, as well as cost, of an additional coronary angiogram.
Conflict of interest: none declared.
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