Europace Advance Access published online on June 2, 2008
Europace, doi:10.1093/europace/eun148
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Is coronary vein angioplasty necessary to provide cardiac resynchronization in selected patients? A case report
ski1,*
c1
y
o2
1 II Coronary Artery Disease Department, Institute of Cardiology, Spartaska 1, 02-637 Warsaw, Poland;
2 I Department of Haemodynamics, Institute of Cardiology, Spartaska 1, 02-637 Warsaw, Poland
Manuscript submitted 29 March 2008. Accepted after revision 12 May 2008.
* Corresponding author. Tel: +48 223434050; fax: +48 228449510. E-mail address: msterlinski{at}poczta.onet.pl
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Abstract |
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Cardiac resynchronization therapy (CRT) has become a recommended method for patients with congestive heart failure (CHF) and cardiac dyssynchrony. In some cases, CRT implantation procedure can be complicated because of anatomic and technical reasons. Some reports describe balloon angioplasty of stenotic heart veins as a method to achieve the target vessel. We present a case of a 58-year-old male with permanent atrial fibrillation and CHF who was referred for CRT. During the implantation of the pacemaker, the diaphragmatic obstacle in coronary sinus (CS) has been passed after many attempts using a balloon catheter with no inflation. The aim of the report is to discuss, in short, the real necessity of venous angioplasty in the CS bed during CRT implantation.
Key Words: Cardiac resynchronization therapy, Venous angioplasty
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Introduction |
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Cardiac resynchronization therapy (CRT) has become a recommended method by the guidelines for selected patients with pharmaco-resistant congestive heart failure (CHF).1
In some cases, CRT implantation procedure is difficult because of many unexpected reasons. In highly specialized centres, the utility of this procedure fell from 15% to 5–6% during the last few years,2 because of new improved methods and some interventional cardiology techniques being adapted. In some reports balloon angioplasty of stenotic heart vein has been described as a method to achieve the target vessel.3 The aim of this paper is to discuss the real necessity of such procedures. |
Case report |
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A 58-year-old male with permanent atrial fibrillation and metabolic syndrome was referred to our hospital, owing to pharmaco-resistant CHF class III NYHA, to be considered for CRT. A borderline ECG and echocardiographic criteria were met: QRS width 120 ms; PEPLV, 140 ms; PEPLV – PEPRV = 42 ms. Left ventricle ejection fraction was 0.20 and left ventricular end-diastolic diameter was 69 mm. In coronary angiography atherosclerotic changes were not found. The patient was finally accepted as a CRT-pacing candidate.
During implantation after coronary sinus (CS), easy intubation into its distal segment was not achieved, despite using different guide-wires and electrophysiology electrodes. Venography revealed poor contrasting of CS distal from visible diaphragmatic obstacle (Figure 1), which was successfully crossed by 0.014 in. angioplasty guide-wire. Neither the electrode nor the contrasting catheter passed over the wire. Finally, the catheter for coronary balloon angioplasty of 20 mm/8.0 mm was placed, but inflation was not performed. After the balloon was removed, OTW electrode was easily led to the distal part of the CS and placed only in the acceptable site of the great cardiac vein without any complications (Figure 2). Pacemaker programme was set on VVI mode with a basic rate of 70/min and optimal V-V delay by echo set on 20 ms with a pacing response to sensed ventricular events. Three months of follow-up demonstrated clinical improvement.
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Discussion |
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CRT has become an accepted and commonly used method of CHF treatment particularly because of increasing efficacy and safety due to New techniques development. One of the main problem is to achieve an optimal LV stimulation through proper electrode placement. Difficulties result often from anatomical venous bed pattern, such as atypical, tortuous CS ostium anatomy, presence of venous valve, thrombi, or stenosis, postoperative deformation, functional constriction, narrowing and tortuosity of potential target vein, and finally, absence of vessels in the desired location. Various methods adapted from interventional cardiology are used to resolve these problems. In patients with target vein stenosis, successful venous balloon angioplasty and stenting were recently described.3
Such procedures seem to be useful to improve blood flow in stenotic large heart veins. Significant CS or large heart vein stenosis that produce increased coronary perfusion pressure gradient, may result in CHF or ischaemic symptoms.4 According to the opinion of the authors small veins angioplasty during CRT implantation in fact does not dilate stenotic changes, but actually removes obstacles for lead positioning. In one of the presented case, there was no haemodynamic symptoms of CS stenosis. The most probable reason for the difficulty of electrode passing was the presence of vein diverticulus or valve (as it commonly happens). That is why it was sufficient to move it or deform it with guide-wire and balloon catheter instead of crushing by angioplasty. Authors suggest that heart veins anatomy and histology confirm this opinion,5 but certainly further observations are needed. Avoiding angioplasty minimizes invasive interference in heart venous system, allows to implant CRT successfully, and may decrease potential early and late complications. Conflict of interest: none declared.
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References |
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[1] Vardas PE, Auricchio A, Blanc JJ, Daubert JC, Drexler H, Ector H, et al, for Task force for Cardiac Pacing and Cardiac Resynchronisation Therapy of the ESC. Cardiac pacing and cardiac resynchronisation therapy guidelines. Eur Heart J (2007) 28:2256–95.
[2] Lewicka-Nowak E, Sterliski M, Dbrowska-Kugacka A, Macig M, Kutarski A, Wilczek R, et al. Complications of permanent biventricular pacing in patients with advanced heart failure. Folia Cardiol (2005) 12:343–53.
[3] Kowalski O, Lenarczyk R, Prokopczuk J, Pruszkowska-Skrzep P, Zieliska T, Sredniawa B, et al. Effect of percutaneous interventions within the coronary sinus on the success rate of the implantations of resynchronization pacemakers. Pacing Clin Electrophysiol (2006) 29:1075–80.[CrossRef][Medline]
[4] Santoscoy R, Walters HL 3rd, Ross RD, Lyons JM, Hakimi M. Coronary sinus ostial atresia with persistent left superior vena cava. Ann Thorac Surg (1996) 61:879–82.
[5] Kawashima T, Sato K, Sato F, Sasaki H. An anatomical study of the human cardiac veins with special reference to the drainage of the great cardiac vein. Ann Anat (2003) 185:535–42.[Web of Science][Medline]
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