Article Text
Statistics from Altmetric.com
A 68-year-old man with heart failure, ischaemic left ventricular dysfunction, left bundle branch block and previous coronary artery surgery underwent upgrade of an existing dual chamber internal cardioverter-defibrillator to a biventricular system.
The procedure was performed via the left subclavian vein approach. Coronary sinus angiography demonstrated a single lateral coronary vein but this vein had a tight proximal stenosis which prevented the passage of a pacing lead (panel A—see arrow at stenosis).
The coronary vein was engaged with a JR4 6 French coronary guide catheter. Using balloon support (1.5×12 mm Maverick), the lesion was crossed with a PT Graphix guidewire, predilated (panel B), and a stent (2.5×18 mm Vision) was deployed with an excellent angiographic result (panel C—after venous stenting). A 4 Fr unipolar pacing lead was passed over the guidewire, through the stented lesion, into the distal vein (panel D). Excellent pacing parameters were obtained with no diaphragmatic twitch.
Three months after the implant the patient’s symptomatic status was significantly improved and the left ventricular lead threshold was stable.
The pathological basis for the observed stenosis is unclear but may relate to extrinsic compression from pericardial adhesions caused by prior cardiac surgery. Coronary venoplasty and stenting is a valuable technique for facilitating percutaneous placement of a left ventricular pacing lead in cases where venous stenosis/angulation is present. This may avoid the need for lead placement in a suboptimal anatomical position or thoracoscopic epicardial lead placement, which is more invasive and risky in a patient with previous cardiac surgery.
Acknowledgments
This article has been adapted from Fox D J, Lee H S, Eisenberger M, Davidson N C. Use of percutaneous angioplasty to facilitate implantation of the left ventricular pacemaker lead for CRT Heart 2008;94:158