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Coronary venous angioplasty to a ring- like stricture preventing left ventricular lead insertion/Sol ventrikul lead implantasyonunu onleyen strikture uygulanan koroner venoz anjiyoplasti.

Introduction

Cardiac resynchronization therapy (CRT) is an alternative therapy in patients with severe systolic heart failure with dyssynchronous ventricular contraction and severe symptoms (NYHA III-IV) despite optimal medical therapy (1). The operators sometimes confront limitations to implant left ventricular lead in coronary veins. These include unsuitable branching angle of coronary veins and tortuosity of coronary sinus anatomy, postoperative deformation, presence of venous valves, absence of vessel in target location, and coronary venous stenosis (2, 3).

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We here describe coronary venous angioplasty before left ventricular lead insertion in a patient with coronary venous stenosis.

Case Report

A 57-year-old male patient with drug refractory heart failure underwent biventricular pacemaker implantation. During the procedure, guiding catheter was engaged into the coronary sinus ostium, and coronary venography was undertaken to choose target coronary vein for left ventricular lead insertion. A posterior coronary vein was found to be appropriate for lead implantation. The lead could not be introduced into the distal posterior coronary vein due to a stenosis caused by ring like stricture in the proximal portion of the vein (Fig. 1, Video 1. See corresponding video/movie images at www.anakarder.com). A coronary wire was advanced through the narrowing. The stenotic portion of the coronary vein was dilated with 2.5 x 10 mm angioplasty balloon with 9 atm pressure (Fig. 2, Video 2. See corresponding video/movie images at www.anakarder.com). Following dilatation, left ventricular lead was easily introduced into the posterior coronary vein without any complication (Fig. 3). Duration of the procedure was 50 minutes. Length of hospitalization was 3 days. Postoperative echocardiography did not reveal any pericardial effusion. Pacemaker follow-up showed effective biventricular stimulation.

Discussion

The target coronary vein should be carefully selected for optimal left ventricular stimulation during CRT (4). However, there are some limitations preventing optimal lead implantation to target vein such as branching and tortuosity of coronary veins, postoperative deformation, presence of venous valves, and venous stenosis (2, 3).

The incidence of venous stenosis has been reported to be approximately 2-3.5% (3, 5-7). Venous stenosis may be due to scarring from myocardial infarction, coronary artery bypass graft surgery, previous implantation of venous leads, or ring like strictures (5, 6). Although venous angioplasty is considered to be safe and effective method to overcome venous stenosis, serious complications may ensue such as rupture, perforation, dissection and thrombosis of the coronary vein (3). Therefore, close hemodynamic monitoring and control echocardiography should be done whenever coronary venous angioplasty is performed. Overinflation should be avoided, and smaller balloon compared to target vein should be chosen for angioplasty to minimize the risks of the procedure (7). This procedure should be applied by physicians who are experienced in the field of coronary angioplasty, and it should be reserved for cases whenever it is strictly necessary.

Conclusion

Implantation of coronary venous lead is technically the most difficult part of biventricular pacing. Strictures in the target vein are rare abnormalities impeding left ventricular lead implantation. Angioplasty for dilation of strictures seems to be the most appropriate solution. However, angioplasty also carries some risks of complications, therefore it should be applied by experienced operators.

Video 1. A ring-like stricture at the ostium of target coronary vein preventing left ventricular lead insertion

Video 2. Application of balloon angioplasty to dilate stricture

References

(1.) Swedberg K, Cleland J, Dargie H, Drexler H, Follath F Komajda M, et al. Guidelines for the Diagnosis and Treatment of Chronic Heart Failure: executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Eur Heart J 2005; 26: 1115-40. [CrossRef]

(2.) Osman F, Kundu S, Tuan J, Pathmanathan RK. Use of coronary venous angioplasty to facilitate optimal placement of left ventricular lead during CRT Pacing Clin Electrophysiol 2009; 32: 281-2. [CrossRef]

(3.) Yi F Wu F Shen M, Wang H, Guo W, Li W, et al. Coronary vein angioplasty to facilitate implantation of left ventricular lead. Europace 2010;12:1600-3. [CrossRef]

(4.) Rossillo A, Verma A, Saad EB, Corrado A, Gasparini G, Marrouche NF 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: 1120-5. [CrossRef]

(5.) 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. [CrossRef]

(6.) Luedorff G, Grove R, Kranig W, Thale J. Different venous angioplasty maneuvers for successful implantation of CRT devices. Clin Res Cardiol 2009; 98: 159-64. [CrossRef]

(7.) Soga Y, Ando K, Yamada T, Goya M, Shirai S, Sakai K, et al. Efficacy of coronary venoplasty for left ventricular lead implantation. Circ J 2007; 71: 1442-5. [CrossRef].

Ali Deniz, Oguz Akkus, Mehmet Kanadasi, Mesut Demir

Department of Cardiology, Faculty of Medicine, Cukurova University, Adana-Turkey

Address for Correspondence/Yazisma Adresi: Dr. Ali Deniz, Cukurova Universitesi Tip Fakultesi, Kardiyoloji Anabilim Dali, Adana-Turkiye Phone: +90 505 396 19 78 E-mail: alideniz78@gmail.com

Available Online Date/Cevrimici Yayin Tarihi: 22.04.2013

doi: 10.5152/akd.2013.113
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Title Annotation:Case Reports/Olgu Sunumlari
Author:Deniz, Ali; Akkus, Oguz; Kanadasi, Mehmet; Demir, Mesut
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Date:Jun 1, 2013
Words:855
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