Key Clinical Mesage
Coronary venous stenosis is an uncommon finding in patients referred for cardiac resynchronization therapy device implantation. Nonetheless, it may result in suboptimal lead positioning for chronic left ventricular (LV) pacing. Coronary venous angioplasty is a technique that can be performed relatively easily and safely to enable LV lead passage beyond a stenosis.
Keywords: cardiac resynchronization therapy, percutaneous coronary intervention, Stenosis
1. INTRODUCTION
We present a case of cardiac resynchronization therapy (CRT) device implantation, complicated by the presence of a coronary vein stenosis. Although the incidence of coronary venous stenosis is low, ranging from 1% to 4% in a population referred for CRT implantation, it may result in suboptimal LV lead positioning or even abandonment of a transvenous approach and subsequent referral for epicardial LV lead placement. The largest delay in mechanical contraction in a patient with left bundle branch block (LBBB) is often located in the posterolateral region, which is therefore the preferred location for chronic LV pacing.1 Since the long‐term effect of CRT is dependent upon optimal LV lead positioning, additional techniques such as coronary venous angioplasty may be warranted to enable optimal LV lead positioning.
2. CASE REPORT
The case concerned a 63‐year‐old man who was admitted to the hospital after suffering out‐of‐hospital cardiac arrest due to ventricular fibrillation (VF). His medical history consisted of coronary artery bypass grafting in 1987 and an inferior myocardial infarction in 1997. He lost consciousness during physical exercise, after which cardiopulmonary resuscitation was successfully performed by bystanders using an automated external defibrillator. The electrocardiogram (ECG) on admission showed a sinus rhythm with a typical LBBB and QRS duration of 160 ms (Figure 1). Echocardiography revealed an overall severely depressed left ventricular (LV) function (ie, the LV ejection fraction measured 30%) without overt regional wall‐motion abnormalities or significant valvular abnormalities. Gadolinium‐enhanced magnetic resonance imaging demonstrated extensive scarring of the inferior wall, as well as vasodilator stress‐induced ischemia of the posterolateral wall. Coronary angiography showed proximal occlusion of the native coronary artery system, with patent coronary artery bypass grafts and collateral filling of a posterolateral side branch of the circumflex artery. It was deemed unlikely that revascularization would prevent future cardiac arrest, mainly due to preexistent extensive scarring of the inferior wall, or significantly improve LV ejection fraction. Because the patient experienced no anginal symptoms and the extent of myocardial ischemia was limited, the lesion was treated conservatively. Subsequently, the patient was scheduled for defibrillator implantation with CRT (CRT‐D), according to the current ESC and AHA/ACC guidelines.2, 3
Figure 1.
Baseline ECG before CRT device implantation
After the usual pre‐operative measures, venous access was obtained via cephalic vein cutdown. The shock electrode (Sprint Quattro Secure™, Medtronic, Minneapolis, MN) was placed in the interventricular septum. The coronary sinus (CS) was cannulated with a guiding sheath (Attain Command™ MP, Medtronic). Subsequently, balloon‐assisted venography (Attain Clarity™ model 6225, Medtronic) was performed revealing two potentially suitable target vessels, a posterolateral vein and a side branch of the mid‐cardiac vein. The posterolateral vein was selectively cannulated with a soft tip, 0.014‐inch guidewire (Whisper Guide Wire, Abbott Vascular). A quadripolar LV lead (Attain™ Performa™ S 4598‐78cm, Medtronic) was advanced over the wire, but could not be introduced into the target vessel due to presumed lack of backup. Subsequently, a subselection catheter (Attain Select II™ 90°, Medtronic) was advanced to the target vessel os, after which selective venography revealed a stenosis in the proximal part of the vein (Figure 2). A second attempt with a straight quadripolar LV lead (Attain™ Performa™ Straight 4398‐78cm, Medtronic) and subselection catheter as backup was also failed. Anatomically, the posterolateral vein was deemed the most optimal position for chronic LV pacing, due to the absence of scarring in this region. Furthermore, the patient was expected to have a reasonable chance of becoming a responder to CRT (ie, a typical LBBB with QRS duration >150 ms is a class 1 indication for CRT).1 Therefore, it was decided to continue with the procedure and pursue transvenous LV lead placement and, after consultation with a senior interventional cardiologist, to perform coronary venous angioplasty of the stenosis to enable LV lead passage. Coronary venous angioplasty was performed with an over‐the‐wire PTCA balloon (2.5 × 12 mm EMERGE™ noncompliant, Boston Scientific, Marlborough, MA). Gradual inflation resulted in complete balloon expansion at 6 atmospheres (Figure 3). Subsequently, a quadripolar LV lead (Attain™ Performa™ Straight 4398‐78 cm, Medtronic) could easily traverse the stenosis (Figure 4). The acute stimulation threshold was <1.0 V, and no diaphragm stimulation was observed at maximum output (10 V). The atrial electrode (CapSureFix Novus™, Medtronic) was placed in right atrial appendage. No procedural complications occurred, and the patient was discharged the following day after adequate lead positioning was confirmed by chest X‐ray.
Figure 2.
Stenosis of the proximal part of the posterolateral vein (highlighted by asterisk)
Figure 3.
Balloon angioplasty of the narrowed segment
Figure 4.
Successful lead placement after venous dilatation
3. DISCUSSION
Several case series have been published on the results and safety of coronary vein angioplasty for the treatment of target vessel stenosis, comprising a total of ~60 subjects.4 The success rate of transvenous LV lead placement ranged from 88% to 100%. Complications are rare, but include coronary vein rupture or perforation with pericardial effusion, dissection, or thrombosis.5 The reported balloon diameters ranged from 2.5 to 4.0 mm, depending on the size of the target vessel. The diameter of the subselection catheter may facilitate selection of the appropriate balloon diameter, by aiding in estimating target vessel size. Balloon inflation pressure should be increased gradually until the stenosis is overcome and balloon indentation has disappeared, although care should be taken to inflate beyond the nominal pressure as this increases the risk of vessel perforation.6 Hence, the use of noncompliant PTCA balloons is preferred. Owing to the risk of complications, it is advisable that coronary venous angioplasty only be performed by operators with experience in coronary interventions, or either in close collaboration with an interventional cardiologist.
4. CONCLUSION
Coronary venous angioplasty is an effective and safe technique to facilitate transvenous LV lead placement in the presence of a coronary venous stenosis.
CONFLICT OF INTEREST
None declared.
AUTHOR CONTRIBUTION
SAJT: prepared the manuscript and figures. JBRMS and GJMT: commented on the manuscript.
Timmer SAJ, de Swart JBRM, Tahapary GJM. A case of coronary venous angioplasty to facilitate left ventricular lead placement. Clin Case Rep. 2018;6:2431–2433. 10.1002/ccr3.1893
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