Europace Advance Access originally published online on July 4, 2008
Europace 2008 10(9):1118-1120; doi:10.1093/europace/eun181
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
CASE REPORTS
High-pressure balloon angioplasty of coronary sinus vein
Kieran Dauber* and
Gerry Kaye
Department of Cardiology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102, Australia
Manuscript submitted 1 May 2008. Accepted after revision 19 June 2008.
* Corresponding author. Tel: +61 7 32402381. E-mail address: kieran_dauber{at}health.qld.gov.au
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Introduction
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Biventricular pacing is an accepted therapy for heart failure.
With increasing rates of implantation, anatomical problems with
the coronary sinus will become more evident.
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Case report
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A 52-year-old man with non-surgical ischaemic cardiomyopathy
underwent implantation of a biventricular defibrillator. The
coronary sinus was engaged with a CSEH sheath (Guidant Ltd,
St Paul, MN, USA) via the left subclavian approach. Imaging
of the venous system showed a patent postero-lateral vein with
a tight stenosis proximally (
Figure 1). Sublingual nitrate
was administered without radiographic change in the stenosis.
An over-the-wire left ventricular (LV) pacing lead was used.
The guide wire (EDS Whisper wire, Guidant Ltd, St Paul, MN,
USA) passed with ease but the bipolar LV lead (Easytrak II French
size 5.4, Guidant Ltd, St Paul, MN, USA) could not be passed.
Also, small-sized unipolar lead (Easytrak I, French size 4.8,
Guidant Ltd, St Paul, MN, USA) could not be passed. A 3.0 mm
Maverick angioplasty balloon (Boston Scientific, Natick, MA,
USA) was dilated at the stenosis site to 14 atm. A clear balloon
indent was seen during inflation, which persisted throughout
the inflation. A further attempt was made without success when
passing the bipolar lead. A 3.5
x 15 mm Maverick balloon (Boston
Scientific, Natick, MA, USA) (rated burst pressure 12 atm) was
then inserted and inflated to 22 atm at which stage the indent
in the balloon disappeared (
Figures 2 and
3). At this moment,
the patient complained of a brief sharp pain in the back. Blood
pressure remained stable throughout. Repeat angiography showed
almost complete resolution of the stenosis. Subsequent passage
of the LV was uneventful with a pacing threshold of 1.8 V.
Although balloon angioplasty of the coronary sinus vein has
been described previously,
1
this is the first report of very
high-pressure inflation without complication. Other authors
have reported the use of cutting balloon angioplasty to facilitate
the placement of coronary sinus lead.
2 Interventions to the
coronary sinus have been reported to improve the short-term
implant success and long-term stability of the coronary sinus
leads.
3
Usual pressure inflation within the coronary artery is 10–16 atm. The mechanism of the venous stenosis can only be surmised but it is likely that either an external fibrous band around the vein was responsible for the radiographic findings or possibly a venous entrapment phenomenon similar to that described in peripheral veins. This might explain the high pressure required to dilate the stenosis. Although high-pressure inflation at this site must be associated with the risk of venous rupture, this did not occur in this case.
Conflict of interest: G. K. has received lecturing fees from Medtronic Inc.
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References
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[1] Hansky B, Lamp B, Minami K, Heintze J, Krater L, Horstkotte D, et al. Coronary vein balloon angioplasty for left ventricular pacemaker lead implantation. J Am Coll Cardiol (2002) 40:2144–9.
[Abstract/Free Full Text][2] Alberto Lopez J, Hernandez E. Transvenous implantation of a coronary sinus lead for left ventricular pacing after cutting balloon angioplasty. Pacing Clin Electrophysiol (2007) 30:568–70.[CrossRef][Medline]
[3] Kowalski O, Lenarczyk R, Prokopczuk J, Pruszkowska-Skrzep P, Zeilin Ska 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]
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Introduction
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