Cardiac Rhythm Management
Articles Articles 2010 December

Successful LV Lead Implantation Following Intra-Coronary Sinus Nitroglycerin

1CHRISTOPHER RANDALL ELLIS, MD and 2KRIT JONGNARANGSIN, MD

1 Cardiac Electrophysiology, Vanderbilt Heart and Vascular Institute, Nashville, TN
2 Division of Cardiovascular Medicine, Cardiac Electrophysiology, University of Michigan, Ann Arbor, MI

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ABSTRACT. We report a case of successful left ventricular (LV) lead implantation following intracoronary sinus nitroglycerin (NTG) for isolated lateral coronary sinus branch venous spasm. Spasm of the vessel prevented optimal LV lead placement. Target vessel vasospasm should be considered in the differential diagnosis of causes of abrupt venous branch closure and inability to track an LV pacing lead into the vessel of interest. Intracoronary sinus NTG injection may facilitate making the diagnosis and prevent abandonment of an ideal pacing location.

KEYWORDS. coronary sinus, venous spasm, lead implantation, intracoronary sinus nitroglycerin.

The authors report no conflicts of interest for the published content.
Manuscript received October 7, 2010, final version accepted October 19, 2010.

Address correspondence to: Christopher R. Ellis, MD, Assistant Professor of Medicine, Cardiac Electrophysiology, Vanderbilt Heart and Vascular Institute, 1215 21st Ave South MCE 5414, Nashville, TN 37232-8802. E-mail: christopher.ellis@vanderbilt.edu

Case report

A 62-year-old man with non-ischemic cardiomyopathy, left ventricular (LV) ejection fraction 15% by two-dimensional (2D) echocardiography, left bundle branch block ((LBBB) QRS duration, 168 ms), NYHA Class III congestive heart failure, and complete heart block was referred for right-sided biventricular implantable cardioverter-defibrillator (ICD) system implantation. A previously existing biventricular ICD (St. Jude Medical, St. Paul, MN) from two years prior was extracted from the left due to device infection with Enterobacter sp. six weeks before. The previous LV lead was in a low postero-lateral venous branch, which was chronically occluded. A temporary transvenous pacing wire was placed prior to definitive therapy.

Right-sided axillary venous access was obtained using the modified Seldinger technique.1 Right atrial pacing and right ventricular ICD leads (St. Jude Medical 1688TC, St. Jude Medical 7120 Durata) were inserted and appropriately positioned. Coronary sinus (CS) cannulation was performed with a St. Jude Medical CS sheath and a Glidewire (Terumo, Somerset, NJ). The CS os was easily cannulated and the Terumo wire advanced into an appropriate lateral venous branch. A CS venogram was then performed (Figure 1), showing a widely patent lateral CS target vessel. A Whisper 0.014 guide wire (Abbott Vascular, Abbott Park, IL) was inserted into the same lateral CS vein, but multiple attempts to advance a bipolar St. Jude Medical 1156T, a unipolar Medtronic 4193 (Minneapolis, MN), and a bipolar St. Jude Medical 1158T pacing lead were unsuccessful due to obstruction from venous spasm of the entire lateral vein at its take-off (Figure 2). After 65 min of attempted cannulation (CS sheath and Whisper wire position were unchanged), 100 µg of nitroglycerin (NTG) was injected directly into the CS via a Berman balloon-tipped catheter with balloon occlusion of the CS followed by a 5-ml saline flush, with immediate relief of the venous spasm. The St. Jude Medical 1156T lead was then easily placed over a Whisper wire into the target vessel (Figure 3). All leads tested adequately with >99% biventricular pacing (QRS duration, 115 ms); defibrillation threshold at implant was 10 joules.

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Figure 1: Coronary sinus venography at baseline showing large patent lateral target venous branch.


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Figure 2: Lateral branch spasm; St. Jude Medical 1056, Medtronic 4193, and St. Jude Medical 1156T pacing leads over Whisper wire could not be inserted due to ostial spasm.


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Figure 3: Final placement of St. Jude Medical 1156T pacing lead after injection of 100 µg of intracoronary sinus nitroglycerin.

Discussion

Inability to place the LV pacing lead in an appropriate lateral CS branch due to main CS spasm relieved by balloon venoplasty has previously been reported.2 Difficulty accessing the CS due to the presence of a proximal CS valve, venous stenosis, spasm, or superior take-off has also been described.3,4 We report a potential cause for abandoning optimal lateral target vein placement due to lateral CS venous branch spasm during LV pacing lead implantation. Possible mechanisms responsible for venous spasm include guide catheter manipulation of the CS or branch ostia, guide wire or LV pacing lead tip induced ostial spasm (due to mechanical trauma), endothelial dysfunction, and systemic reaction to anesthesia or hypotension during surgery. It is possible that during routine CS venography, initial injection of intracoronary sinus NTG followed by saline flush via the Berman catheter or CS sheath may allow optimal visualization and facilitate cannulation of lateral target vein branches. We believe our case represents the first report of successful LV pacing lead insertion specifically past an obstructed lateral branch of the CS with the use of direct intracoronary sinus NTG injection. Appropriate LV lead placement (avoidance of anterior placement) is essential to biventricular pacing clinical response, and improvement in LV ejection fraction.5 Target vessel vasospasm should be considered in the differential diagnosis of causes of abrupt venous branch closure, and inability to track an LV pacing lead into the vessel of interest. Intracoronary sinus NTG injection may facilitate making the diagnosis and prevent abandonment of an ideal pacing location.

References

  1. Higgs ZC, Macafee DA, Braithwaite BD, et al. The Seldinger technique: 50 years on. Lancet 2005; 366:1407–1409.
  2. Woollett IF, Pinney S, Magnano AR. Balloon dilatation of coronary sinus spasm during placement of a biventricular pacing lead. Circulation 2005; 111:e304–e305.
  3. Russo V, De Crescenzo I, Ammendola E, et al. Coronary sinus spasm during left ventricular lead implantation for biventricular pacing. Europace 2007; 9:528–530.
  4. Von Ludinghausen M. The venous drainage of the human myocardium. Adv Anat Embryol Cell Biol 2003; 168:I-VIII, 1–104.
  5. Rossillo A, Verma A, Saad EB, et al. Impact of coronary sinus lead position on biventricular pacing: mortality and echocardiographic evaluation during long-term follow-up. J Cardiovasc Electrophysiol 2004; 15:1120–1125.

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