High-pressure balloon angioplasty of coronary sinus vein

Biventricular pacing is an accepted therapy for heart failure. With increasing rates of implantation, anatomical problems with the coronary sinus will become more evident. A 52-year-old man with non-surgical ischaemic cardiomyopathy underwent implantation of a biventricular defibrillator. The coronary sinus was engaged with a CSEH sheath (Guidant Ltd, St Paul, MN, USA) via the left subclavian approach. Imaging of the venous system showed a patent postero-lateral vein with a tight stenosis proximally ( Figure 1 ). Sublingual nitrate was administered without radiographic change in the stenosis. An over-the-wire left ventricular (LV) pacing lead was used. The guide wire (EDS Whisper wire, Guidant Ltd, St Paul, MN, USA) passed with ease but the bipolar LV lead (Easytrak II French size 5.4, Guidant Ltd, St Paul, MN, USA) could not be passed. Also, small-sized unipolar lead (Easytrak I, French size 4.8, Guidant Ltd, St Paul, MN, USA) could not be passed. A 3.0 mm Maverick angioplasty balloon (Boston Scientific, Natick, MA, USA) was dilated at the stenosis site to 14 atm. A clear balloon indent was seen during inflation, which persisted throughout the inflation. A further attempt was made without success when passing the bipolar lead. A 3.5 × 15 mm Maverick balloon (Boston Scientific, Natick, MA, USA) (rated burst pressure 12 atm) was then inserted and inflated to 22 atm at which stage the indent in the balloon disappeared ( Figures 2 and 3 ). At this moment, the patient complained of a brief sharp pain in the back. Blood pressure remained stable throughout. Repeat angiography showed almost complete resolution of the stenosis. Subsequent passage of the LV was uneventful with a pacing threshold of 1.8 V. Coronary sinus venogram in the left anterior oblique 30° position showing a stenosis (arrow) in the postero-lateral vein. Balloon inflation within the proximal vein showing a clear indentation mid-balloon. Coronary sinus angiogram taken after balloon inflation showing the resolution of the previous stenosis. Although balloon angioplasty of the coronary sinus vein has been described previously, 1 this is the first report of very high-pressure inflation without complication. Other authors have reported the use of cutting balloon angioplasty to facilitate the placement of coronary sinus lead. 2 Interventions to the coronary sinus have been reported to improve the short-term implant success and long-term stability of the coronary sinus leads. 3 Usual pressure inflation within the coronary artery is 10–16 atm. The mechanism of the venous stenosis can only be surmised but it is likely that either an external fibrous band around the vein was responsible for the radiographic findings or possibly a venous entrapment phenomenon similar to that described in peripheral veins. This might explain the high pressure required to dilate the stenosis. Although high-pressure inflation at this site must be associated with the risk of venous rupture, this did not occur in this case. Conflict of interest : G. K. has received lecturing fees from Medtronic Inc.