Heart on a string: a novel approach to managing difficult access to the left pericardiacophrenic vein for phrenic nerve stimulation.

This case highlights the difficulties in pacing lead implantation for transvenous phrenic nerve stimulation to treat central sleep apnea in heart failure. Cannulation of the left pericardiacophrenic vein (PPV) initially failed due to vessel tortuosity. On the basis of sound knowledge of collateral vessels, the inferior phrenic vein (IPV), which drains into the inferior vena cava, was intubated using a guide catheter. A guidewire could be retrogradely advanced via the IPV to the left PPV and brachiocephalic vein. The wire was captured via a snare catheter, such that the heart was held "on a string", thereby providing adequate support for lead placement.