Multi-site multi-polar left ventricular pacing through persistent left superior vena cava in tricuspid valve disease

Figures

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  Fig. 1. Contrast venogram of the middle cardiac vein and lead course after slitting of sub-selection catheter. (a) The coronary sinus (CS) was hugely dilated, as reflected by the wide separation between the guide catheter and the right atrial lead. An Amplatz AL1 angiography catheter was used to engage the ostium of the middle cardiac vein (MCV). Retrograde filling from the MCV outlined an antero-lateral side branch faintly, but its origin from the main CS body was not clearly seen. (b) As soon as an Amplatz AL2 sub-selection catheter was slit, the quadripolar left ventricular lead immediately formed a large loop in the right atrium without disturbing the distal lead tip position. Any slight reduction of the loop caused the lead tip to move basally out of the MCV.

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  Fig. 2. Direct engagement of an antero-lateral side branch of the coronary sinus through persistent left superior vena cava. The origin of antero-lateral side branch from the coronary sinus was not well visualized by cross-filling from the middle cardiac vein. The side branch was only partially engaged with a Judkins JR6 catheter after trying multiple other angiography catheters. An angioplasty guide wire manipulated into the side branch provided enough support for the JR6 and then the guide catheter to enter the branch, allowing a bipolar lead to be placed within.

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  Fig. 3. Chest X-rays showing bipolar and quadripolar left ventricular leads in different side branches of the coronary sinus. The left ventricular lead courses are outlined in red. The lead in the middle cardiac vein has a large hairpin loop skirting around the entire right atrium. The tricuspid annuloplasty ring can be clearly seen in the lateral view.