Download DIFFICULT INTUBATION OF THE CORONARY SINUS (CS

DIFFICULT INTUBATION OF THE CORONARY
SINUS (CS) DURING IMPLANTATION OF
CARDIAC RESYNCHRONIZATION THERAPY
(CRT) SYSTEM IN PATIENTS WITH EXTREMELY
DILATED HEART CAVITIES
Sv. Iovev, Y. Dzhorgova, B. Slavchev, M. Stoilova
UNSHAT “St. Ekaterina” – Sofia
Author for contacts: Sv. Yovev, MU – Sofia, Clinic of Cardiology, Department of Electrocardiostimulation and Electrocardiophysiology,
UNSHAT “St. Ekaterina”, 52A Pencho Slaveikov Blvd. – Sofia, Bulgaria; tel: +359 2 915 97 24, e-mail: [email protected]
Abstract: The final phase of the disease “Cardiomyopathy” manifests itself with significant reduction in the pump function of the heart and extremely dilated heart cavities. The dilation of the heart cavities can reach 2-3 times their normal
size, as this is often associated with internal deformation and change of the spatial orientation of cardiac structures. In this
case report, we show one of the most common problems with implantation of Cardiac Resynchronization Therapy (CRT)
systems – the intubation of the coronary sinus.
Case report
The presented patient is 37-year-old, 80 kg, 178 cm,
body mass index (BMI) 25.24, diagnosed with idiopathic dilated cardiomyopathy and total heart failure (THF).
The disease is diagnosed 7 years before the procedure,
and since then it’s been accompanied by manifestations of HF. The conducted invasive diagnostics in the
past - selective coronary angiography (SCAG) (2009),
presented no evidence of ischemic genesis of the disease. In the last year the symptoms accelerated, despite
the optimal therapy with beta-blockers, cardiac glycosides, diuretics, angiotensin-converting enzyme (ACE)
inhibitors.
From the echocardiography (EchoCG) - left ventricular
ejection fraction (LVEF) - 16% with telediastolic volume
(TDV–LV) - 242 ml, telesystolic volume (TSV-LV) - 162ml,
mitral insufficiency – up to 1st degree. Narrow chamber
complex - 90 ms. The tissue Doppler determined major
criteria (SD - standard deviation - 41, IVD - intraventricular delay - 80 msec) for ventricular asynchrony.
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The patient was evaluated as indicated for CRT.
The CRT stimulator model “Stratos” – DDDR type was
implanted, using left subclavian vein access (v. subclavia sinistra). The lead, stimulating the left ventricle,
model “Corox” bipolar, was placed in the posterior vein
of the left ventricle (PVLV). The lead, stimulating the
right ventricle, “Selox 69 cm”, was placed on a typical
position – the apex of right ventricle. The lead for the
right atrium, “Selox 53 cm” was also placed on a standard position – the auricle of the right atrium (fig.1, 2
and 3). Optimal parameters for stimulation and sensing were registered for all the three leads (tab.1)
In the early post procedure period, there was significant improvement of the general status. On the second post procedure day, the conducted tissue Doppler presented: LVEF 20% with recovered intra- and
inter-ventricular synchronicity.
J Clin Med. 2010; 3(2):34-36
Discussion
The change in the spatial anatomy and deformation
of heart cavities are present in all patients with cardiomyopathy. This change also affects the anatomy of the
coronary sinus (CS), creating difficulties in its intubation during implantation of CRT stimulation. In the
presented case, the standard CS introducer appears
to have insufficient length, thus making it difficult to
intubate and perform routine retrograde occlusive venography.
Fig 1
CS – Coronary Sinus
GCV – Great Cardiac Vein
PVLV – Posterior Vein of the Left Ventricle
Therefore, a non-occlusive/direct venography was
applied, which visualized part of the anatomy of CS
with prominent PVLV branch. The choice to implant
LV lead in this branch is motivated by the fact that
PVLV is a good target vessel, reaching the maximum
lateral wall of LV. The absence of this branch would
have further complicated the procedure and would
have required changing the model and type of introducer.
Fig 2
CS – Coronary Sinus
GCV – Great Cardiac Vein
PVLV – Posterior Vein of the Left Ventricle
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The presented report demonstrates the demand for
availability of wide range of different models and types
of introducers. Currently, the so-called rigid introducers with fixed angle of curvature and length are still
offered. The occurrence of the above mentioned cases
requires the development of flexible introducers for
intubation of the CS.
Fig 3
LV – Left Ventricle
RV – Right Ventricle
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