CRT-D implantation: one procedure, two problems

A 70-year-old patient with chronic ischemic cardiomy-opathy (NYHA III, left ventricle ejection fraction (EFLV) = 15%, left bundle branch block (LBBB), percutaneous coronary intervention (PCI) left anterior descending artery (LAD) in 2006 and right coronary artery (RCA) in 2007), after an episode of sustained VT, terminated pharmacologically , was qualified for a cardiac resynchronization therapy (CRT-D) procedure (class IA). Reduction of heart failure was impossible despite optimal pharmacotherapy. The defibrillation lead was implanted in the right ventricle apex through the left cephalic venotomy, and the atrial lead was implanted in the right atrium appendage by a subclavian vein approach. Optimal atrial and ventricular pacing parameters were obtained. The left ventricular (LV) lead was implanted through left subclavian venepuncture with difficulties of coronary sinus (CS) cannulation. The cannulation of the vein running on the front wall of the heart – the marginal vein (M. von Ludinghausen type III of CS anatomy – Figure 1) – was enabled by using an LV introducing set with small curvature (Medtronic Attain 6216A-MB2). Administered contrast visualized single tributaries and the CS trunk. Cannulation of the CS was performed successfully based on the image of performed venography, followed by implantation of the LV lead in the wide lateral vein. Excellent pacing parameters were obtained in the distal location , although associated with diaphragm stimulation. More proximal reposition helped to gain acceptable LV stimulation parameters without any side effects. While the introducing sheath was removed, LV lead was dislocated with loss of effective stimulation. Instead of the previous standard Medtronic guide-wire, a hemodynamic guidewire (Abbott Hi-Torque Balance Heavyweight – Abbott-GW) was inserted into the lead, with the help of which an ineffective attempt of lead reposition was performed, using the over-the-wire technique. Due to earlier difficulties with CS cannulation we decided to introduce a new sheath using Abbott-GW, the ending of which was already in the CS. To do this part of the procedure it was necessary to remove the lead and leave only the Abbott-GW. The sheath was inserted, the Abbott-GW removed, and the LV lead was implanted again in the lateral vein with optimal electrical parameters. The sheath and the standard guidewire were removed without lead reposition. After the procedure was accomplished, reduction of the Abbott-GW's length (25 cm ending with fragile structure) was noticed. In a chest X-ray the fragment of the guidewire was localized between the superior vena cava (SVC) and pulmonary trunk …