Placement of a Left Ventricular Pacing Lead After Balloon Angioplasty of a Coronary Vein Stenosis
Coronary Sinus Obstruction as a Complication After Mitral Valve Operation
A 77-year-old man was admitted to our hospital for revision of his single-chamber ventricular pacemaker to a biventricular pacing device. He showed class 4 symptoms of congestive heart failure, a history of idiopathic dilated cardiomyopathy, chronic atrial fibrillation, a 15% ejection fraction during echocardiography, and left bundle-branch block with a QRS duration of 170 ms. At implantation, venography of the coronary sinus revealed a severe stenosis in the coronary venous system prohibiting the passage of the left ventricular pacing lead (Figure 1 and Movie I).
The obstacle within the coronary sinus was identified as being close to an implanted prosthetic mitral valve annulus. The cardiac surgery, which included mitral and tricuspidal valve reconstruction, had been performed 5 years earlier at another hospital, for severe tricuspidal and mitral valve regurgitation.
To advance the left ventricular pacing lead to the optimal target vein, angioplasty was performed over a 0.014-inch guidewire with a 2 × 20-mm standard coronary angioplasty balloon inflated to 800 kPa (Figure 2 and Movie II).
The coronary venogram revealed a moderate residual stenosis (Figure 3 and Movie III). Subsequently, the left ventricular pacing lead could be advanced into a posterolateral left ventricular vein (Figure 4 and Movie IV).
Postimplantation transthoracic echocardiography ruled out pericardial effusion or other mechanical complications. Coronary sinus obstructions caused by cardiac surgery may represent an under-recognized and reversible reason for inability to place biventricular pacemaker leads.
The online-only Data Supplement can be found with this article at http://circ.ahajournals.org/cgi/content/full/118/9/e136/DC1.