Balloon Dilatation of Coronary Sinus Spasm During Placement of a Biventricular Pacing Lead
A 48-year-old man with a history of idiopathic dilated cardiomyopathy, Class 3 symptoms of congestive heart failure, and left bundle-branch block with QRS duration of 164 ms was referred for revision of his implantable cardioverter-defibrillator to a biventricular pacing device. At the time of initial cardioverter-defibrillator implantation at an outside hospital, a coronary sinus (CS) lead was not placed because of the inability to cannulate the CS ostium. Because we also were unable to access the CS ostium from the left subclavian vein approach, a deflectable recording catheter with an angiographic lumen was used to enter the coronary sinus from the right femoral vein to define the location of the CS. Venography showed a superiorly directed coronary sinus ostium, which in our experience is a common reason for inability to cannulate the CS from the subclavian approach. In addition, extensive CS spasm was identified (Figure 1). Direct infusion of nitroglycerin did not relieve the spasm, which progressed to complete occlusion (Figure 2). A standard venography balloon was manually inflated at successively more distal positions to cross the region of spasm (Figure 3). After balloon dilatation, an angioplasty guidewire was advanced with an over-the-wire technique, followed by a permanent pacemaker lead. At 3 months’ follow-up, thresholds remained intact and the patient reported an improvement in his functional capacity. CS spasm may represent an underrecognized and reversible reason for inability to place biventricular pacing devices.