Case Report
A 55-year-old man presented with heart failure due to dilated
hypertrophic cardiomyopathy. His electrocardiogram revealed a right
bundle branch block with a wide QRS complex (QRS length=208 ms) and
first-degree atrioventricular block (PR length=316 ms). He had undergone
catheter ablation four times for atrial fibrillation / tachycardia and
had taken diuretics and beta-blockers for the same. Despite rhythm
control and adequate medication therapy, he still had dyspnea and
refractory leg edema. To manage the patient’s uncontrolled heart
failure, we decided to implant a CRT pacemaker. Written informed consent
was obtained from the patient before the CRT pacemaker implantation.
Angiography of the coronary sinus was used to determine whether the
posterolateral vein was suitable to deploy the LV lead. We selected the
active fixation LV pacing lead (Attain Stability Quad 4798, Medtronic,
Dublin, Ireland) for implantation, which is a quadripolar LV lead with
an active fixation helix assembly designed to position the lead in the
coronary sinus.3 A large-curve-type coronary sinus
cannulation catheter (Attain Command + SureValve Integrated Valve,
Medtronic, Dublin, Ireland) was used to deploy the lead using a standard
over-the-wire technique, which involved advancing the pacing lead over
the wire into the desired location, with the distal electrodes
positioned in the mid-LV segment. However, the lead did not advance
smoothly as the target vessel was tortuous (Figure 1). Moreover, the
pacing threshold was high, despite the deep insertion of the LV lead. To
overcome this, we used an extra support guidewire (GRAND SLAM, Asahi
Intecc, Aichi, Japan) and a 135-degree subselection catheter (Attain
Select II + SureValve sub-selection catheter, Medtronic); however, we
were unable to advance the LV lead further.
Subsequently, we attempted to engage the cannulation catheter deep
within the coronary sinus as this could provide better support to pass
the LV lead through the tortuous vessel. To achieve this, we applied the
anchor technique, which is already reported as a technique for obtaining
superior guiding catheter support during the advancement of a balloon
catheter in coronary angioplasty4 Once the lead was
placed in the deepest position, it was rotated clockwise to achieve
active temporary fixation of the lead. Next, we inserted and advanced
the cannulation catheter while gently pulling the temporarily fixed LV
lead. As the LV lead was fixed, it did not fall out of position despite
being pulled, and we were able to advance the cannulation catheter
deeper. As a result, superior cannulation catheter support was obtained
without the LV lead falling out of position. Following this, the LV lead
was rotated counterclockwise, and the fixation mechanism was released
from the vein wall. Further, the lead was advanced to the middle lateral
position, and refixation was performed. Using this method, the LV lead
was successfully and smoothly passed through the tortuous vessel. We
called this method the “lead anchor technique” (Figure 2). By
obtaining superior cannulation catheter support, we were able to implant
the LV lead at a low pacing threshold and without a phrenic nerve
stimulation site (Figure 3). After CRT implantation, the pacing
threshold was not increased, the QRS complex improved to 170 ms, and
heart failure could be controlled.