Placement of Biventricular Lead in the Coronary Sinus Using a Steerable Catheter

Case Presentation

The patient is a 57-year-old white male who has New York Heart Association (NYHA) class III heart failure with left ventricular enlargement and left ventricular ejection fraction of 20%, with left bundle branch block and a QRS width of 154 ms. Despite optimal medical therapy, including Coreg 25 mg PO bid, Lisinopril 20 mg po qd, spironolactone 25 mg and Lasix 80 mg daily, the patient is still limited by marked dyspnea on exertion and chronic fatigue. After informed consent, the implantation of a biventricular pacing device was agreed upon. The patient was brought to the electrophysiology lab in the fasting, nonsedated state. Informed consent was obtained and he was prepped in a sterile fashion. Sedation consisted of Versed and Fentanyl. Initially, a 4 French (Fr) sheath was inserted into the right femoral artery and a 4 Fr JL4 diagnostic catheter was used to perform left coronary angiography. Using the levophase of the left coronary injection, the course of the coronary sinus was identified, and by using a long cineangiogram run, this image was effectively stored for use as a road map. The patient s left chest was then prepped and draped, and a left pectoral pocket was created. The subclavian vein was accessed and three separate guidewires were placed in the subclavian vein. Using a 9 Fr introducer, the middle guidewire was utilized initially. The guidewire and the introducer were removed and the Attain delivery system (Medtronic, Minneapolis, Minnesota), model 6218A 50 cm straight guide catheter, was deployed through the 9 Fr sheath over a large curve, 7 Fr, steerable Luma-Cath catheter (Boston Scientific/Irvine Biomedical, Natick, Massachusetts), model 1110-L-7-25-L. The Luma-Cath is a decapolar steerable catheter with a hollow lumen, through which a 0.025´´ Cook (Bloomington, Indiana) guidewire, 260CM, model TSCS-25-260-3, can be deployed. Using this delivery system, the Luma-Cath was passed fluoroscopically to the os of the coronary sinus. In the 30 degree LAO projection, the Luma-Cath was placed in the vicinity of the coronary sinus os as determined by the road map previously obtained. Using a combination of anatomical localization and intracardiac electrogram recordings, the coronary sinus os was localized, and the 0.025´´ wire was passed to the distal coronary sinus. The Luma-Cath then was tracked over the wire, and the coronary sinus location was confirmed by the presence of atrial and ventricular electrograms on each pair of electrodes. The guide catheter was then advanced over the Luma-Cath, and placed in the mid coronary sinus. The Luma-Cath with the 0.025 guidewire was then withdrawn. A Medtronic Attain venogram balloon, model 6215-80 CM was then advanced to the tip of the guide catheter and the balloon was inflated. Contrast was injected and coronary sinus anatomy was delineated with its branches. The balloon was then deflated and the venogram catheter withdrawn. The Medtronic Attain OTW4193-88CM lead was then advanced to the coronary sinus and positioned in an anterolateral branch. Pace/sense function revealed a sensed R wave of 18 MV with a capture threshold of 1.0 V at 0.5 ms. Leaving the guide catheter in position, attention was then focused on the two remaining leads. A 9 Fr introducer was placed over one of the two remaining proximal guide catheters in the subclavian vein while a 7 Fr introducer was placed over the most medial guidewire, and through these two sheaths, the right ventricular and right atrial lead were positioned. Both leads were active fixation leads, and were placed in position, actively fixed to the myocardium, and pace/sense function was assessed. Once adequate position was obtained, both leads were secured to the fascia proximally, using silk sutures on sewing sleeves. Leaving the stylet in the coronary sinus lead, but withdrawing it to approximately the mid CS position, the Tuohy valve was loosened and removed over the proximal portion of the lead and its stylet, while maintaining the delivery system guide catheter and lead in position in the coronary sinus. Using the slitting device, the guide catheter was then slit and removed. The 9 Fr introducer was then carefully retracted while ensuring stable positioning of the distal tip of the 4193 lead in the coronary sinus as well as ensuring minimal additional slack at the entrance to the coronary sinus as the introducer was withdrawn. Finally, using fluoroscopic guidance, the stylet was removed from the 4193 lead. The sewing sleeve was then secured to the fascia and all three leads were connected to the InSync® pacemaker (Medtronic), model 8040. The pocket was closed in a surgical fashion and the patient was returned to his room in stable condition where a post procedure chest x-ray was obtained.

Discussion

This patient underwent a successful biventricular pacemaker implantation. Using a steerable Luma-Cath catheter and an anatomical electrogram-guided approach, coronary sinus access and lead placement can be obtained quickly and safely.