Left Ventricular Lead Placement for CRT

DR MAHENDRA CARDIOLOGY,JIPMER

• Anatomy of the coronary sinus-• runs in the posterior coronary groove between the LA and left ventricle.• CS ostium drains into posteroseptal region of the RA near the tricuspid valve.• partially covered by a Thebesian valve (a remnant of the embryonic right valve)

in roughly 60% of pts• second valve (the valve of Vieussens) located at the junction of the great cardiac

vein and the vein of Marshall is present in about 8% of pts.

• 5 branch-• 1.great cardiac vein• 2. vein of marshall• 3.posterior vein of LV• 4.middle cardiac vein • 5.small cardiac vein

Right Atrial Anatomical Features

• Tricuspid annulus• Fossa ovalis• Eustachian ridge• Coronary sinus• Thebesian valve• Eustachian fossa• Inferior vena cava

AP view

Interventional approach to lead placement• following steps: • 1) localization of the CS ostium via contrast puffs through a preformed guide

catheter• 2) cannulation of the CS with a sheath advanced over the guide catheter (with or

without wire support)• 3) cannulation of the target branch.• 4) advancement of the LV lead through the delivery-guide over an 0.014-inch

angioplasty wire.

CS Cannulation Catheters

Venogram• Balloon occludes most coronary sinuses – inflates to 10 mm

(pre-measure 1.25 cc syringe)

• Lead with a guide wire

• Balloon can be inflated and deflated several times

• Contrast solution can be injected through catheter

Selecting Vein for LV Lead Placement

A. Lateral (marginal) cardiac veinB. Postero-lateral cardiac veinC. Posterior cardiac vein

AB

C

D

E

► Target: Left ventricular free wall (Lateral, Poster-lateral, Antero-lateral)1,2,3

1 Ansalone G, et al. JACC. 2002;39:489-499. 2 Butter C, et al. Circulation. 2001;104:3026-3029. 3 Auricchio A, et al. Am J Cardiol. 1999;83:136D-142D.

A

BCD

E

LAO View

► Sub-optimal lead location:

D. Middle cardiac veinE. Great cardiac vein

Remove Catheter: Slitting Procedure

difficult lead implantation• most common reasons for failed LV lead implantation-• inability to access the CS ostium.• inability to advance the lead into the target branch• acute lead dislodgement or instability

• When initial attempts at CS localization fail, selective coronary angiogram with cine fluoroscopy of the venous phase may help locate a high or unusual ostial insertion.

• prominent Thebesian valve or a steep takeoff due to atrial enlargement may hinder advancement of the catheter into the main body of the CS-

• wire can be placed into the main CS• straight 5-French hydrophilic catheter• occlusive balloon can be used as an anchor

• Partial occlusion to the target branch is present-• invasive angioplasty techniques• Snares technique

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