Europace Advance Access originally published online on April 16, 2007
Europace 2007 9(7):514-515; doi:10.1093/europace/eum051
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PACING
Successful coronary sinus lead placement after stenting of coronary vein stenosis
1 Department of Cardiology, Türkiye Yüksek 
htisas Hospital, Ankara, Turkey;
2 Department of Cardiology, Faculty of Medicine, Dicle University, Diyarbak
r, Turkey
Manuscript submitted 27 December 2006. Accepted after revision 5 March 2007.
* Corresponding author: Tel: +90 4122488001; fax: +90 2488264. E-mail address: droalyan{at}yahoo.com
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Abstract |
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In this paper, we describe a 62-year-old man with ischemic cardiomyopathy who underwent biventricular pacing and left ventricular lead could be implanted after stenting of a coronary vein stenosis.
Key Words: Coronary vein stenosis, Cardiac resynchronization therapy, Coronary vein stenting
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Case |
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A 62-year-old man with ischemic cardiomyopathy, New York Heart Association Class III heart failure, despite optimal medical therapy, and sustained ventricular tachycardia, was hospitalized for a biventricular pacemaker and implantable cardioverter defibrillator implantation. He had coronary artery bypass grafting in 2001. Standard 12-lead electrocardiogram revealed right bundle branch block (RBBB) with QRS duration of 160 ms. Transthoracic 2D echocardiography revealed that left ventricular ejection fraction was 26%, and there were signs of considerable inter- and intraventricular mechanical dyssynchronies. During the biventricular pacemaker implantation, the coronary sinus (CS) was cannulated with 9 Fr catheter delivery system, and venogram was performed. However, CS angiography showed a severe narrowing in the posterolateral branch (Figure 1A). Although a guidewire could easily cross the stenosis, the pacemaker lead could not pass the stenotic area. Since there were no suitable venous branches in the posterior to the lateral area, we decided to dilate the stenosis. Bare metal stent (3.5 x 18 mm) crossed the stenotic area and was implanted (Figure 1B and C). After the stent implantation, we easily implanted the CS lead bypassing the stented area (Figure 1D). Finally, the right ventricular lead and atrial lead were implanted into the apex of the right ventricle and right atrial appendage, respectively.
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Recently, cardiac resynchronization therapy (CRT) has been showed a significant benefit in HF patients with RBBB, although clinical trials of CRT have not included many patients with RBBB.1
The iatrogenic or congenital abnormalities in CS such as stenosis, dissection, or absence may make the implantation of CS leads impossible in 8–10% of cases.2,3 Coronary vein dilatation by angioplasty or stenting to permit the implantation of a CS lead should be considered when there is no alternative vessel. But skilful interventions such as stenting or careful steering can allow successful implantation in much more cases.
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[1] Eqoavil CA, Ho RT, Greenspon AJ, Pavri BB. Cardiac resynchronization therapy in patients with right bundle branch block: analysis of pooled data from the MIRACLE and Contak CD trials. Heart Rhythm (2005) 2:616–8.[CrossRef][Web of Science][Medline]
[2] Cazeau S, Leclercq C, Lavergne T, et al. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med (2001) 12:873–80.
[3] Walker S, Levy S, Rex S, et al. Initial United Kingdom experience with the use of permanent, biventricular pacemakers. Europace (2000) 2:233–9.
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