Fengwei Zou1, Seth J Worley2, Torkel Steen3, Matthew McKillop4, Santosh Padala5, Susan O'Donoghue6, Basar Candemir7, Khalil Kanjwal8, Michael Kaufman4, Sahar Mouram9, Matthew Sellers10, David Strouse6, Athanasios Thomaides6, Devi Nair11, Cyrus A Hadadi6, Alexander Kushnir12. 1. Georgetown University School of Medicine, Washington, District of Columbia. 2. Georgetown University MedStar Heart & Vascular Institute, Washington, District of Columbia; Penn Medicine Lancaster General Health, Lancaster, Pennsylvania. Electronic address: seth@mcworley.com. 3. Oslo University Hospital Ullevaal, Oslo, Norway. 4. University of Florida College of Medicine, Gainesville, Florida. 5. Virginia Commonwealth University Health System, West Hospital, Richmond, Virginia. 6. Georgetown University MedStar Heart & Vascular Institute, Washington, District of Columbia. 7. Ankara University Cebeci Heart Center, Fakülteler, Çankaya/Ankara, Turkey. 8. McLaren Greater Lansing Hospital, Lansing, Michigan. 9. Cardiologue, Rythmologie et Stimulation Cardiaque, Faculté de Médecine Paris Descartes, Paris Diderot, Paris, France. 10. Upstate Cardiology, Greenville, South Carolina. 11. St. Bernards Medical Center, Jonesboro, Arkansas. 12. Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeon, New York, New York.
Abstract
BACKGROUND: Coronary sinus (CS) ostial atresia/abnormalities prevent access to the CS from the right atrium (RA) for left ventricular (LV) lead implantation. Some patients with CS ostial abnormalities also have a small persistent left superior vena cava (sPLSVC). OBJECTIVE: The purpose of this study was to describe CS ostial abnormalities and sPLSVC as an opportunity for LV lead implantation and unrecognized source of stroke. METHODS: Twenty patients with CS ostial abnormalities and sPLSVC were identified. Clinical information, imaging methods, LV lead implantation techniques, and complications were summarized. RESULTS: Forty percent had at least 1 previously unsuccessful LV lead placement. In 70%, sPLSVC was identified by catheter manipulation and contrast injection in the left brachiocephalic vein, and in 30% by levophase CS venography. In 30%, sPLSVC was associated with drainage from the CS into the left atrium (LA). When associated with CS ostial abnormalities, the sPLSVC diameter averaged 5.6 ± 3 mm. sPLSVC was used for successful LV lead implantation in 90% of cases. In 80%, the LV lead was implanted down sPLSVC, and in 20%, sPLSVC was used to access the CS from the RA. Presumably because of unrecognized drainage from the CS to the LA, 1 patient had a stroke during implantation via sPLSVC. CONCLUSION: When CS ostial abnormalities prevent access to the CS from the RA, sPLSVC can be used to successfully implant LV leads. In some, the CS partially drains into the LA and stroke can occur spontaneously or during lead intervention. It is important to distinguish sPLSVC associated with CS ostial abnormalities from isolated PLSVC.
BACKGROUND: Coronary sinus (CS) ostial atresia/abnormalities prevent access to the CS from the right atrium (RA) for left ventricular (LV) lead implantation. Some patients with CS ostial abnormalities also have a small persistent left superior vena cava (sPLSVC). OBJECTIVE: The purpose of this study was to describe CS ostial abnormalities and sPLSVC as an opportunity for LV lead implantation and unrecognized source of stroke. METHODS: Twenty patients with CS ostial abnormalities and sPLSVC were identified. Clinical information, imaging methods, LV lead implantation techniques, and complications were summarized. RESULTS: Forty percent had at least 1 previously unsuccessful LV lead placement. In 70%, sPLSVC was identified by catheter manipulation and contrast injection in the left brachiocephalic vein, and in 30% by levophase CS venography. In 30%, sPLSVC was associated with drainage from the CS into the left atrium (LA). When associated with CS ostial abnormalities, the sPLSVC diameter averaged 5.6 ± 3 mm. sPLSVC was used for successful LV lead implantation in 90% of cases. In 80%, the LV lead was implanted down sPLSVC, and in 20%, sPLSVC was used to access the CS from the RA. Presumably because of unrecognized drainage from the CS to the LA, 1 patient had a stroke during implantation via sPLSVC. CONCLUSION: When CS ostial abnormalities prevent access to the CS from the RA, sPLSVC can be used to successfully implant LV leads. In some, the CS partially drains into the LA and stroke can occur spontaneously or during lead intervention. It is important to distinguish sPLSVC associated with CS ostial abnormalities from isolated PLSVC.
Keywords:
Coronary sinus ostial atresia; Left ventricular lead; Small persistent left superior vena cava; Thromboembolic stroke; Unroofed coronary sinus