The document discusses challenges that can occur during coronary sinus lead implantation for cardiac resynchronization therapy, including anatomical abnormalities, difficulties accessing the coronary sinus or its branches, lead instability, and complications like phrenic nerve stimulation or high pacing thresholds. Specific challenges covered include stenosis, tortuosity, small vessel size, failure to cannulate, dissections, and potential solutions using devices, angiography, and stenting. The document also presents a case example of a patient who experienced left ventricular lead dislocation after initial successful cardiac resynchronization therapy device implantation.

1. Alireza Ghorbani Sharif,MD
Interventional Electrophysiologist
Tehran Arrhythmia Clinic
January 2018
Difficult CS Lead
Implantations

2. Enhanced coronary CT angiography. (a) Anterolateral view of the heart shows the anterior
interventricular vein (AIV) coursing through the anterior interventricular sulcus parallel to the
left anterior descending artery (LAD). It continues as the great cardiac vein (GCV) in the left
atrioventicular groove along with the left circumflex artery (LCX).

3. Posteroinferior view of the heart shows the GCV continuing as the CS, which
finally drains into the right atrium (RA). Also shown are the posterior
interventricular vein (PIV) accompanying the posterior descending artery (PDA),
the posterior vein of the left ventricle (PVLV), and the left marginal vein (LMV)

5. Veins Anatomy

6. Difficult CS lead Implantations
1. Acquired or congenital abnormities of venous system
2. Failure to CS cannulation
3. Failure to access CS branch:
- Inability to deliver LV lead to CS branch vessel due to absence
or small size, tortuosity and narrowing or stenosis
4. LV lead instability
5. Phrenic Nerve Stimulation (PNS)
6. High Pacing Thresholds (HPT)

7. Acquired or congenital
abnormities of venous system
• Obstruction of left subclavian vein
• Persistent left SVC

8. Acquired or congenital abnormities
of venous system

9. Subclavian Stenosis

10. Subclavian Stenosis

11. Failure to CS cannulation
• Valves obstructing the catheter or lead
advancement
• Variable CS ostium location
• Dilated right atrium
• Severe kinking of the vein
• Small vessel size of CS

12. Key points in Cannulating
Coronary OS
PRO CON
LV Lead
Placed
FIRST
1. No interference from
other leads being in the
way
2. May save time & money
1. Other
means of
back-up
pacing
RV Lead
Placed
FIRST
1. Back up pacing
2. Idea of RA dimension &
general cardiac anatomy
1. May get in way
of LV sheath

13. Key points in Cannulating
Coronary OS
• The OS is in the posteroseptal region of the
RA & may be obstructed by Thebesian valve
• The OS is not on the floor of the RA, but up
1 to 2 cm
• As the RA dilates the OS may be
more posterior and ~1 cm higher

14. Key points in Cannulating
Coronary OS
HF pts tended to have
higher CS origin than non-
HF pts (p<0.001)
Height of CS origin slightly
more variable in HF pts
1.2
0.6
2.2
1.4
0.3
0
0.5
1
1.5
2
2.5
HF Non-HF
Height(in
Cm)
HF Non-HF

15. • Tricuspid annulus
• Coronary sinus
• Thebesian valve
Membranous valve covering postero-inferior aspect of CS ostium In 10-
20% of cases, can impede CS cannulation
Valves
Difficult Cannulation or Lead Advancement

18. Vieussens’ valve

19. Coronary Sinus Cannulation
• Sheath of different curve
• Inner sheaths, coronary angiography catheter (for
example: JR, Amplatz)
• Maneuvers: Contrast flushing test at LAO in low RAO
CCW rotation , guidewires
• EP catheters
• Venous phase coronary angiography
• ICE and steerable fiberoptic endoscope

20. Attain Command Family

21. RAPIDO Cut-Away Family

23. MB2
Standard or high
takeoffs of the CS
Multipurpose
Standard or high
takeoffs of the CS
Curve allows
cradling in a medium
to large size RA

24. Extended Hook
Vertical takeoff
of CS
Use with an inner
catheter (Attain
Select® II) to reach
across a large
dilated RA
Amplatz
Bypasses
Eustachian Ridge or
Thebesian valve
near or blocking CS

25. Effect of CCW Rotation
First moves to the left
Then, moves downwards
Start here
From: Clinical Cardiac Pacing, Defibrillation and CRT by Ellenbogen

26. Effect of CCW Rotation

27. CS Cannulation by EP catheter

28. Cannulation of CS OS
IEGM to confirm position
A/ V > 1
Atrial signal at the end of the P-wav

29. Cannulate CS
Advancing Deflectable Cath.
CathSheath
LAO: 50oImages compliments of Dr. Randy Lieberman

30. Venous Phase of Coronary
Angiography

31. Venous Phase of Coronary
Angiography

33. Failure to access CS branch
• Inability to deliver LV lead to CS branch
1. Absence or small size veins
2. Narrowing or stenosis
3. Sharply angulated or tortuosity veins
• Complications
1. CS dissection
2. Perforation

34. Coronary Venography
• Provide a visualization of cardiac venous
anatomy
• Insight into size and tortuosity of veins
Key points:
-Venous trauma (advancing balloon too far)
-Vein dissection
-Added risk to patients with renal insufficiency

35. Multiple Views
Notice the origin of the lateral target vessel
LAO View RAO View
Images compliments of Dr. Seth Worley
Target Lateral
Branch
Target Lateral
Branch

36. Collateral Filling of Cardiac Veins

37. Narrowing or Stenosis

38. Narrowing or Stenosis

39. Narrowing or Stenosis

40. Narrowing or Stenosis

41. Sharply Angulated or Tortuous
Target Vein
1. Use an appropriately shaped inner sheath that can
selectively hook the target vein
2. Other techniques include pushing the wire as much
inside the vein as possible to gain extra support, or to
pull the wire while advancing the lead
3. Using second stiffer wire to reduce the tortuosity and
provide extra support

42. Appropriately Shaped Inner Sheath

43. Appropriately Shaped Inner Sheath

44. Pushing the wire to get extra support

45. Pushing the wire to get extra support

46. Double Guidewire

47. Double Guidewire

48. CS Dissection
• Contak CD study: perforation or dissection of the
coronary sinus in 1.6 -1.8%
• Management:
• Surgical approach
• Delay the LV lead implantation after 2 weeks
• Select another cardiac vein

49. CS Dissection

50. CS Dissection

51. CS Perforation

52. LV lead instability
• Macro-disloaction, micro-dislocation rate is
described to be 10%
• We usually use two techniques to stabilize
the lead
1. Retained stylet or guidewire technique for
anchoring LV lead
2. Coronary sinus side branch stenting

53. Retained stylet or guidewire
• Guidewires are prone to fracture
• Stylets are stiffer than guidewires, there is no reason
to believe that there no fracture by stylet
• Difficulty in lead extraction
• The permanent stylet technique should be the last
resort

54. Retained stylet or guidewire

55. Retained stylet or guidewire

56. Coronary Sinus Side Branch Stenting
• Coronary sinus side branch stenting is
a good technique to stabilize the LV
lead position
• But may cause injury to the lead
insulation

57. Coronary Sinus Side Branch Stenting

58. Coronary Sinus Side Branch Stenting

59. Phrenic Nerve Stimulation (PNS)
High Pacing Threshold( HPT)

60. Phrenic Nerve Stimulation (PNS)
High Pacing Threshold( HPT)
• A new quadripolar (LV)
lead with increased
number of pacing
configuration
• Place a coronary stent
besides the precisely
placed LV lead to
stabilize, and to prevent
distal migration

61. Case
• A 73 yr man was a case of ischemic
cardiomyopathy with VT and LBBB
• CRT-D was done successfully and there was
improvement his heart failure
• There was LV lead dislocation after two yeras

62. Case

63. Case

64. Case

65. Case

67. Tehran Arrhythmia Center
WWW.IranEP.org
info@IranEP.org