most important aspect for successful placement of LV lead is understanding of coronary os. anatomy and proper imaging and identification of selected vein.also important to know various method for CS cannulation.

1. Left Ventricular Lead Placement
for CRT
DR MAHENDRA
CARDIOLOGY,JIPMER

2. • 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.

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

4. Right Atrial Anatomical Features
• Tricuspid annulus
• Fossa ovalis
• Eustachian ridge
• Coronary sinus
• Thebesian valve
• Eustachian fossa
• Inferior vena cava

7. AP view

14. 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.

15. CS Cannulation Catheters

16. 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

17. Selecting Vein for LV Lead Placement
A. Lateral (marginal) cardiac vein
B. Postero-lateral cardiac vein
C. Posterior cardiac vein
A
B
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
B
C
D
E
LAO View
► Sub-optimal lead location:
D. Middle cardiac vein
E. Great cardiac vein

21. Remove Catheter: Slitting Procedure

22. 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

23. • 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

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

27. THANK YOU