Download High-pressure balloon angioplasty of coronary sinus vein

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K. Dauber and G. Kaye
Discussion
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.
References
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, Sterliński M, Da˛browska-Kugacka A, Macia˛g 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, Zielińska 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.
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.
CASE REPORT
doi:10.1093/europace/eun181
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
* Corresponding author. Tel: þ61 7 32402381. E-mail address: [email protected]
Received 1 May 2008; accepted after revision 19 June 2008; online publish-ahead-of-print 4 July 2008
Biventricular pacing is an accepted therapy for heart failure. With increasing rates of implantation, anatomical problems
with the coronary sinus will become more evident.
Case report
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.
Balloon angioplasty of coronary sinus vein
Figure 1 Coronary sinus venogram in the left anterior oblique 308 position showing a stenosis (arrow) in the postero-lateral vein.
Figure 2 Balloon inflation within the proximal vein showing a clear indentation mid-balloon.
Figure 3 Coronary sinus angiogram taken after balloon inflation showing the resolution of the previous stenosis.
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A 3.5 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 shortterm 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.
References
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.
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.
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.
CASE REPORT
doi:10.1093/europace/eun165
Successful catheter ablation of atrial fibrillation
in a patient with dextrocardia
Takumi Yamada*, Hugh Thomas McElderry, Harish Doppalapudi, Michael Platonov, Andrew E. Epstein,
Vance J. Plumb, and George Neal Kay
Division of Cardiovascular Disease, University of Alabama at Birmingham, VH B147, 1670 University Boulevard, 1530 3rd
Avenue South, Birmingham, AL 35294-0019, USA
* Corresponding author. Tel: þ1 205 975 4724; fax: þ1 205 975 4720. E-mail address: [email protected]
Received 4 February 2008; accepted after revision 26 May 2008; online publish-ahead-of-print 18 June 2008
A 49-year-old woman with dextrocardia and situs inversus underwent catheter ablation of paroxysmal atrial fibrillation. A contrast injection into the left atrium revealed that the left atrial appendage (LAA) was adjacent to the right-sided (anatomic left) superior pulmonary
vein (PV). After successful isolation of that PV, LAA potentials were recorded from several electrode pairs of a circular PV mapping
catheter. LAA may cause similar difficulties during PVI of the right-sided superior PV in a dextrocardia patient, as during PVI of the
left superior PV in a normal heart.
Case report
A 49-year-old woman with dextrocardia and situs inversus without any underlying disease linked to that disorder was
referred for catheter ablation of drug-refractory paroxysmal atrial fibrillation (AF). Transoesophageal echocardiography
revealed a patent foramen ovale. At the electrophysiological study, a 6 Fr decapolar catheter (Polaris XTM, EP Technologies,
Boston Scientific Corporation, San Jose, CA, USA) was introduced into the coronary sinus via the femoral vein. A 6 Fr quadripolar catheter (VikingTM, Bard Electrophysiology, Lowell, MA, USA) was positioned in the His-bundle region. Trans-septal
catheterization via the patent foramen ovale was successfully achieved using a 7.5 Fr, 3.5 mm tip-irrigated ablation catheter (NAVI-STARTM THERMOCOOLTM, Biosense Webster, Diamond Bar, CA, USA) through the 8 Fr trans-septal sheath (SL2TM, St
Jude Medical, AF Division, Minnetonka, MN, USA) via the femoral vein with fluoroscopic guidance. A contrast injection
into the left atrium via the trans-septal sheath revealed that the left atrial appendage (LAA) was located adjacent to
the right-sided superior pulmonary vein (PV) (Figure 1). After PV angiograms were obtained (Figure 1), circumferential
PV isolation (PVI) was performed with the guidance of a 20-electrode circular mapping catheter (LassoTM, Biosense
Webster). Successful PVI was defined as either the abolition or dissociation of the distal PV potentials and was confirmed