Europace 2006 8(7):506-507; doi:10.1093/europace/eul068
© The European Society of Cardiology 2006. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
CRT
Identification of lateral cardiac veins for cardiac resynchronization therapy
Klaus K. Witte and
John D. Parker*
Division of Cardiology, University Health Network, University of Toronto, Mount Sinai Hospital, Room 1609, 600 University Avenue, Toronto, Ont, Canada, M5G 1X5
Manuscript submitted 28 December 2005. Accepted after revision 18 April 2006.
* Corresponding author. Tel: +1 416 586 4794; fax: +1 416 586 8413. E-mail address: jdp{at}ca.inter.net
Key Words: Heart failure, Cardiac resynchronization therapy, Coronary sinus
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Introduction
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Coronary sinus (CS) venography is used to identify suitable,
usually mid-lateral veins, for left ventricular (LV) lead placement.
Once CS cannulation has been achieved, contrast injection through
a balloon occlusion catheter allows visualization of the CS
and its branches.
Case
We present a 59-year-old patient with long standing chronic heart failure with a previous single chamber implantable defibrillator referred for upgrade to resynchronization therapy. Initial images of the CS revealed no lateral veins (Figure 1). The catheter was withdrawn to the ostium and contrast injection proximally revealed the presence of a separate CS (Figures 2 and 3). Manipulation of the catheter eventually allowed cannulation of this vessel, imaging of the lateral branches (Figure 4), and successful lateral LV lead placement.
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Figure 2. Further contrast venography following withdrawal of the balloon occlusion catheter to the coronary sinus os suggesting a proximal origin of the lateral vein.
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Figure 3. Right anterior oblique view demonstrating separate origin to the venous system draining the lateral cardiac wall.
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Figure 4. Cannulation of the lateral venous system prior to placement of the left ventricular pacing lead.
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Discussion
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Occasionally, during the LV lead placement, contrast venography
will reveal a CS that appears to have no lateral branches. This
is usually a consequence of the injection catheter being advanced
past the origin of the lateral veins. Withdrawing the sheath
and balloon occlusion, catheter back towards the CS ostium and
repeating the injection will allow the proximal branch to be
imaged. In the present case, there appeared to be two CSs running
parallel to each other. Imaging of this vessel required the
removal of the sheath to the base of the right atrium.
Lead placement during the cardiac resynchronization therapy can have a large influence on symptomatic benefit. Posterior-lateral positioning is thought to be associated with a greater chance of response. Therefore, every effort should be made to identify veins that pass over these regions, even if initial imaging does not identify them.
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Acknowledgements
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The authors are grateful to Wilson Chan of the Cardiac Catheterisation
Research Laboratory at Mount Sinai Hospital for help with preparation
of the images.
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Introduction
Discussion