EP Lab Digest - March 2008 - (Page 34)

34 EP CASE STUDY MARCH 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 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 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. 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 (CRTD) device because of its defibrilFigure 2. Venogram demonstrates domilation capacity. He did, however, nant lateral branch with an acute angle take off, followed immediately by an agree to life-improving therapy, “Omega”-shaped tortuosity. so the decision was made to Immediately distal to the tortuosity, implant a Frontier ® II model note narrowing of the vein, consistent with a small myocardial bridge. 5586 cardiac resynchronization pacemaker (CRT-P) (St. Jude Medical, St. Paul, Minnesota) for biven- demonstrated tortuosity that resembled tricular pacing. The patient’s existing the Greek letter omega (Figure 2). pacemaker would be removed, and, Because of the tortuosity of this vein, assuming the existing RA and RV lead a unipolar lead was first considered. measurements remained stable, an LV Typically, unipolar leads track around (coronary sinus) lead would be added to tortuous veins better than bipolar leads, complete the resynchronization vector. due to the fact that unipolar leads have a single electrode, while bipolar leads Choosing and Implanting the have two electrodes. However, unipolar leads limit therapy delivery to unipolar Lead In November 2007, the patient pacing, with no ability to make changes underwent the procedure to implant in pacing settings if adjustments are the Frontier II CRT-P. To gain access, needed after initial surgery. To ensure the CPS Direct ® SL outer guide optimal therapy delivery and to meet catheter (St. Jude Medical, extra wide future pacing needs, the QuickSite® XL curve, model 410115, 47 cm) was used 1058T bipolar lead (St. Jude Medical) via the standard subclavian stick was selected. Its wider separation of approach. The coronary sinus (CS) was bipoles and larger curve at the distal cannulated via standard technique. The end were designed to provide excellent guide catheter was inserted into the maneuverability (Figure 3). To implant the lead, the standard right ventricle, then retracted while counter-clockwise torque was applied. “Floppy Firm” guidewire (model The preformed curve of the guide 4078G, St. Jude Medical) was advanced catheter allowed easy access to the to well beyond the tortuosity. Using an coronary sinus. After occlusive CS over-the-wire approach — after some venography, the only viable target was a initial difficulty — the lead was maneusingle lateral branch, midway up the vered through the 90-degree turn and coronary sinus. There was no visible advanced smoothly past the proximal secondary branch and an atretic poste- challenges. It was placed in the true, left rior lateral branch, so the single lateral lateral mid-ventricular position — an branch was the only acceptable vessel. extremely secure position because the Unfortunately, this vessel had a greater than 90-degree take-off angle and, See CASE STUDY page 37 immediately after this transition, 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 diagnosis Figure 1. Initial ECG demonstrating atrial paced rhythm and a wide left bundle branch. Interrogation of the device confirmed ventricular sensed behavior. 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.

Table of Contents Feed for the Digital Edition of EP Lab Digest - March 2008

EP Lab Digest - March 2008 ECG 101: The Case of a Dizzy Patient with a Left Bundle Branch Block Delayed Defibrillation: Research and Results Interview with Paul S. Chan, MD Contents Letter from the Editor Spotlight Interview: St. Joseph’s Hospital Health Center Parent Heart Watch from 36,000 Feet… Perspectives from the Annual Leadership Conference Clinical Trial Overview: 2008 Are MRI-Safe Pacemakers and Leads on the Horizon? Q & A with J. Rod Gimbel, MD Navigating Tortuous Coronary Sinus Anatomy Using a Bipolar Lead Email Discussion Group: March 2008 Guidelines on ECG Interpretation Spotlight Interview Update: What Have We Learned? The Value of Educating Staff Events Calendar Industry News and Products Classifieds Advertisers Index In Memoriam

EP Lab Digest - March 2008

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