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Taking any Route Possible to Achieve Cardiac Resynchronization | OMICS International
ISSN: 2155-9880
Journal of Clinical & Experimental Cardiology

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Taking any Route Possible to Achieve Cardiac Resynchronization

Haqeel A Jamil*, Michael Lacey and Klaus KA Witte
Leeds Institute of Genetics, Health and Therapeutics, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, United Kingdom
Corresponding Author : Haqeel A Jamil
Leeds Institute of Genetics
Health and Therapeutics
Multidisciplinary Cardiovascular Research Centre
University of Leeds, Clarendon Way, Leeds
United Kingdom, LS2 9JT
Tel: (+44)1133926642
E-mail: [email protected]
Received February 08, 2014; Accepted March 29, 2014; Published April 10, 2014
Citation: Jamil HA, Lacey M, Witte KKA (2014) Taking any Route Possible to Achieve Cardiac Resynchronization. J Clin Exp Cardiolog 5:295. doi:10.4172/2155-9880.1000295
Copyright: © 2014 Jamil HA, et al. This is an open-access article distributed underthe terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
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Left ventricular dysfunction; Cardiac resynchronisation therapy; Heart failure; Left sided superior vena cava
An 85 year old man with non-ischaemic dilated cardiomyopathy, severe left ventricular systolic dysfunction and severe symptoms of heart failure was referred for Cardiac Resynchronisation Therapy (CRT). His resting 12 lead ECG revealed atrial fibrillation with a bradycardic ventricular response despite no rate limiting agents, and a left bundle branch block with the QRS duration of 156 ms.
Positioning of the right ventricular lead (St. Jude Optisense 1999 52cm) was straightforward via a left infraclavicular approach. Accessing the Coronary Sinus (CS) to implant the left ventricular lead was difficult due to repeated cannulation of a small parallel tributary (Figure 1 image A). Retrograde contrast venography using this vein revealed a large CS with a tight proximal stenosis, and a small persistent left sided superior vena cava (PLSVC) (Figure 1 images B and C). Access to the PLSVC was gained using a hyperacute sub-selection catheter (Medtronic Attain Select II), and a hydrophilic coated guidewire (Terumo Glidewire) was passed into the coronary sinus. The PLSV was engaged with a steerable sheath (Medtronic Attain Command system) to provide support for the sub-selection catheter which was advanced into the coronary sinus (Figure 1 image D). Antegrade venography revealed a high lateral vein, with a retrograde junction to the main CS (Figure 1 image E). The Left Ventricular (LV) lead (St Jude Quick Flex micro 1258 88cm) was successfully passed into a satisfactory position (Figure 1 image F). Lead thresholds and positions were stable at 24 hour post procedural device interrogation (Figure 2).
This case describes how standard sheath and catheter shapes used imaginatively can overcome difficult anatomy. A PLSVC is estimated to occur in 0.3% of individuals without congenital abnormalities. It is the most common venous cardiac abnormality, and is most often identified incidentally during pacemaker implantation [1]. Due to increased flow, the CS in patients with a PLSCV is often large, usually making cannulation for LV lead placement during cardiac resynchronisation therapy easy, but achieving a stable lead position more difficult. Our case demonstrates the benefit of doing a complete venogram during CRT implantation and that even a vestigial PLSCV can be used to access the CS for LV lead placement [2,3].

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