Europace Advance Access originally published online on May 15, 2007
Europace 2007 9(7):528-530; doi:10.1093/europace/eum073
© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
BIVENTRICULAR PACING
Coronary sinus spasm during left ventricular lead implantation for biventricular pacing
Vincenzo Russo1,*,
Ilaria De Crescenzo1,
Ernesto Ammendola1,
Ciro Cavallaro2,
Lucio Santangelo1 and
Raffaele Calabrò1
1 Chair of Cardiology, Second University of Naples, Naples, Italy;
2 Division of Cardiology, Monaldi Hospital, Naples, Italy
Manuscript submitted 17 November 2006. Accepted after revision 19 March 2007.
* Corresponding author. Tel: +39(0) 3396354844. E-mail address: v.p.russo{at}libero.it
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Abstract
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The authors present a case of coronary sinus spasm during left
ventricular lead implantation for biventricular pacing relieved
by direct infusion of nitroglycerin.
Key Words: Coronary sinus spasm, CRT, Biventricular pacing, Left ventricular lead, Nitroglycerin
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Case report
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A 60-year-old man with idiopathic dilated cardiomyopathy, ejection
fraction (EF) < 30%, left bundle-branch block with QRS duration
of 160 ms, NYHA class III, and optimal medical therapy
for at least 6 months was referred to our division for cardiac
resynchronization therapy (CRT) using a biventricular pacing
device. Triple puncture of the subclavian vein was used to introduce
separate guidewires and 9-french peel away sheaths for positioning
three pacing leads according to modified Seldinger technique.
1
Right ventricular lead was first implanted and placed via fluoroscopy
in apical position. Atrial lead was positioned in the right
atrium appendage and secured by active fixture. After cannulation
of the coronary sinus (CS) ostium, using a quadripolar electrophysiological
catheter (Josephson curve, Bard Corp., Billerica, MA, USA) and
a pre-shaped guiding sheath (RAPIDO Cut-Away Coronary Sinus
Hook, Guidant Corporation, St Paul, MN, USA), the CS venogram
was performed in order to define the anatomy of the CS branches
and to select the optimal target vein.
Coronary sinus contrast venography showed a complete occlusion of CS with no evidence of tributary veins, probably related to vasospasm (Figure 1). Direct infusion of nitroglycerin relieved the spasm (Figure 2) and allowed to visualize a posterior CS tributary vein, in which left ventricular (LV) epicardial lead was placed using Easytrack lead system (Guidant Corporation). Results of the implantation were assessed from the position of the leads on chest X-ray films (Figure 3) and from the changes in the QRS interval width on 12-lead surface electrocardiogram. CRT device was programmed in atrial synchronous biventricular pacing with the lower rate limit set at 40 bpm, and the upper rate limit set at 130 bpm. At 12 months' follow-up, thresholds remained intact and the patient showed an improvement in his functional capacity.
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Figure 1 Left anterior oblique projection. Contrast venography showing complete occlusion of coronary sinus (CS) related to vasospasm, with no evidence of CS tributary veins. Right atrial and right ventricular leads position are shown.
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Figure 3 Anterior–posterior projection. CRT system in place. The pacing leads in the right atrium and in the apex of the right ventricle are shown. Left ventricular pacing lead is placed in a posterior branch of the coronary sinus.
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Conclusion
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In appropriately selected patients, the leads positioning is
of key importance to obtain a successful cardiac resynchronization
therapy. Intravenous LV lead placement may be difficult with
the presence of anatomical anomalies of the CS, cardiac veins,
and ostial valves.
2 Contrast venography is necessary in order
to diagnose a pre-existing CS vein occlusion or other venous
anomalies that might prevent successful transvenous LV lead
placement. CS spasm may represent an under-recognized and reversible
reason for inability to place biventricular pacing devices.
If the direct infusion of nitroglycerin in CS does not relieve
the spasm, it may be used as a standard venography balloon for
dilating the CS region of spasm.
3
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References
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[1] Higgs ZC, Macafee DA, Braithwaite BD, Maxwell-Armstong CA. The Seldinger technique: 50 years on. Lancet (2005) 366:1407–9.
[CrossRef][Web of Science][Medline][2] Von Ludinghausen M. The venous drainage of the human myocardium. Adv Anat Embryol Cell Biol (2003) 168:1–104.
[3] Woollett IF, Pinney S, Magnano AR. Balloon dilatation of coronary sinus spasm during placement of a biventricular pacing lead. Circulation (2005) 111:e304–5.[Free Full Text]
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Abstract
Case report