Cath Lab Digest - April 2008 - (Page 38)

38 CASE STUDY APRIL 2008 Navigating Tortuous Coronary Sinus Anatomy Using a Bipolar Lead Matthew Trojan, MD Heart Failure Specialist, Oregon Cardiology, and Medical Director of the Heart Failure Program at Oregon Heart and Vascular Institute Eugene, Oregon Figure 1. Initial ECG demonstrating atrial paced rhythm and a wide left bundle branch. Interrogation of the device confirmed ventricular sensed behavior. Case History An 80-year-old male patient presented to his primary care physician with reoccurring panic attacks and dyspnea; the panic attacks and symptoms were worse at night. He was unsuccessfully treated with anti-anxiety medications, and visited the emergency room several weeks later with dyspnea and angina. The patient exhibited classic New York Heart Association Class III symptoms of heart failure; he was unable to walk around his house without becoming fatigued, and was experiencing angina about once a week. The patient had undergone coronary bypass surgery Diagnosis The patient had an electrocardiogram that revealed an atrially paced rhythm and a wide LBBB morphology, with a QRS of 176 (Figure 1). The patient was appropriately diagnosed as suffering from heart failure, rather than an anxiety disorder, and he was directed to meet with a heart failure specialist. In August 2007, a left ventricular angiography was conducted. The RFA was cannulated using the Seldinger technique, and a 5 French sheath was inserted into the artery over a guidewire. The angiography confirmed the ischemic cardiomyopathy cardiac resynchronization pacemaker (CRT-P) (St. Jude Medical, St. Paul, MN) for biventricular pacing. The patient’s existing pacemaker would be removed, and, assuming the existing RA and RV lead measurements remained stable, an LV (coronary sinus) lead would be added to complete the resynchronization vector. Choosing and Implanting the Lead In November 2007, the patient underwent the procedure to implant the Frontier II CRT-P. To gain access, the CPS Direct® SL outer guide catheter (St. Jude Medical, extra wide curve, model 410115, 47 cm) was used via the standard subclavian stick approach. The coronary sinus (CS) was cannulated via standard technique. The guide catheter was inserted into the right ventricle, then retracted while counter-clockwise torque was applied. The preformed curve of the guide catheter allowed easy access to the coronary sinus. After occlusive CS venography, the only viable target was a single lateral branch, midway up the coronary sinus. There was no visible secondary branch and an atretic posterior lateral branch, so the single lateral branch was the only acceptable vessel. Unfortunately, this vessel had a greater than 90-degree take-off angle and, immediately after this transition, demonstrated tortuosity that resembled the Greek letter omega (Figure 2). Because of the tortuosity of this vein, a unipolar lead was first considered. Typically, unipolar leads track around tortuous veins better than bipolar leads, due to the fact that unipolar leads have a single electrode, while bipolar leads have two electrodes. However, unipolar leads limit Figure 2. Venogram demonstrates dominant lateral branch with an acute angle take off, followed immediately by an “Omega”shaped tortuosity. Immediately distal to the tortuosity, note narrowing of the vein, consistent with a small myocardial bridge. The patient was appropriately diagnosed as suffering from heart failure, rather than an anxiety disorder, and he was directed to meet with a heart failure specialist. several years prior to this event, and he had a history of coronary artery disease, hypertension, hyperlipidemia, ischemic cardiomyopathy, and a left ventricle ejection fraction (EF) of 20 percent. He also had a history of sick sinus syndrome for which a pacemaker had been implanted. The pacemaker provided atrial pacing and ventricular sensing, with the intrinsic signal showing a left bundle branch block (LBBB). His symptoms developed while on a good medical therapy of aspirin, carvedilol, rosuvastatin calcium, valsartan, furosemide, and clopidogrel. diagnosis and showed three-vessel coronary artery disease, abnormal LV function, and ejection fraction of 10%. Therapy Decision The 80-year-old patient expressed a main goal of improving quality of life and did not want to pursue therapies aimed at prevention of sudden cardiac arrest. He declined the suggestion of a cardiac resynchronization therapy defibrillator (CRT-D) device because of its defibrillation capacity. He did, however, agree to life-improving therapy, so the decision was made to implant a Frontier® II model 5586 Figure 3. The St. Jude Medical QuickSite XL lead (Model 1058T) with large s-shaped curve fixation mechanism and steerable tip. Reprinted with permission from EP Lab Digest 2008;3(8):34,37. Editor’s Note: This article underwent peer review by one or more members of EP Lab Digest’s editorial board. therapy delivery to unipolar pacing, with no ability to make changes in pacing settings if adjustments are needed after initial surgery. To ensure optimal therapy delivery and to meet future pacing needs, the QuickSite® XL 1058T bipolar lead (St. Jude Medical) was selected. Its wider separation of bipoles and larger curve at the distal end were designed to provide excellent maneuverability (Figure 3).

Table of Contents Feed for the Digital Edition of Cath Lab Digest - April 2008

Cath Lab Digest - April 2008 Kaiser San Rafael Medical Center Orbital Atherectomy: A New Treatment for Complex Peripheral Arterial Disease Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Contents Clinical Editor’s Corner CEU Education Center The Missing Link in STEMI Interventions — Thrombus Aspiration during Primary Percutaneous Coronary Intervention Predicting Stent Thrombosis Using A Clinical Risk Score Use of a New Guidewire: The Tigerwire Should I Stay or Should I Go? Weighing Options for New Opportunities Navigating Tortuous Coronary Sinus Anatomy Using a Bipolar Lead The National Society of Radiology Practitioner Assistants (NSRPA) Holds 9th Annual Educational Conference For Medical Imaging Physician Extenders and Mid-Level Healthcare Providers Cath Lab & Beyond: A Meeting Update The Ten-Minute Interview with… Dale Hansen RT, CVT Sometimes, You Just Know Twin Circumflex Arteries: A Rare Coronary Artery Anomaly What Do You Think? Meetings Calendar News from the American College of Cardiology (ACC) Scientific Session and the Society of Cardiovascular Angiography & Interventions (SCAI) Annual Scientific Sessions in Partnership with the ACC i2 Summit Clinical & Industry News Cath Laughs Classifieds Advertisers Index

Cath Lab Digest - April 2008

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