Cardiac Rhythm Management
Articles Articles 2010 December

Commentary: Successful LV Lead Implantation Following Intra-Coronary Sinus Nitroglycerin


Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA

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Dr. Epstein reports receiving fellowship support and honoraria from Biotronik, Boston Scientific, Medtronic, and St. Jude Medical. He also reports receiving research grants from Biotronik, Boston Scientific, Cameron Health, Medtronic, and St. Jude Medical.
Manuscript received October 20, 2010, final version accepted October 28, 2010.

Address correspondence to: Andrew E. Epstein, MD, Electophysiology Section, Division of Cardiovascular Medicine, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104. E-mail:

The thrill of victory and the agony of defeat represent the polarized emotions that accompany left ventricular (LV) lead implantation. How happy we are when the coronary sinus venogram shows more than one acceptable vein, and how demoralizing it is when there are none. And then, there is the frustration of seeing a good vein and have it disappear! Drs. Ellis and Jongnarangsin have shared with us an elegant solution to one cause of this depressing scenario. To think of giving nitroglycerin (NTG) in the heat of battle is impressive; any simple intervention with great utility is elegant.

Are there downsides to giving 100 mcg of NTG in the coronary sinus? Probably not many. The dose is small, and even in our hemodynamically compromised patients, it almost certainly will not have a systemic effect. When given in a coronary artery, hypotension is virtually never a problem. On the positive side, there is little to lose by giving NTG. Furthermore, it may even be useful to dilate veins that are not in spasm but simply borderline small so veins that appear unusable at first glance become possibly useful. One could also argue that for the patient with no great targets, settling for an apparently suboptimal vein may in fact work quite well. We should take heart from the contributions of Dr. Singh on behalf of the MADIT-CRT investigators showing that virtually any LV lead position other than the apex provides effective cardiac resynchronization therapy.1 Indeed, more veins than we have been taught to be acceptable may in fact be just fine. I would argue that the majority of responders will respond wherever the LV lead is (within reason), and the majority of nonresponders will remain nonresponders irrespective of what we do. Responders are likely those who are not so far into their disease process that any intervention will fail;2 they are so-called “healthy responders” in the statistical/epidemiologic literature.3

Ellis and Jongnarangsin have not only given us an elegant tip on how to salvage an unusual problem encountered when implanting an LV lead, but also a technique that may be helpful to enlarge patent veins that, in the absence of pharmacologic manipulation, are too small to accommodate an LV lead.


  1. Singh J, et al. Heart Rhythm Society Late-Breaking Clinical Trials. Presented at: Heart Rhythm 2010 Meeting, May 13, 2010.
  2. Goldenberg I, Vyas AK, Hall WJ, et al. Risk stratification for primary implantation of a cardioverter-defibrillator in patients with ischemic left ventricular dysfunction. J Am Coll Cardiol 2008; 51:288–296.
  3. Hallstrom AP, Greene HL, Huther ML. The healthy responder phenomenon in non-randomized clinical trials. Stat Med 1991; 10:1621–1631.