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Relevant clinical history and physical exam
A 64 years-old gentleman presented to us with SOB-E for last 2 years. His symptom was NYHA Class 3 for last 7 months despite optimal medical therapy. Echocardiography revealed dilated LV cavity with LVEF of 25%. He had normal coronaries in angiography.
Relevant test results prior to catheterization
The ECG showed sinus rhythm, LBBB with QRSd of 164 m sec. He had expected life span more than 1 year. Therefore, a CRT-D implantation was planned.
Relevant catheterization findings
His only coronary sinus tributary draining the lateral LV wall had critical ostial stenosis with retrograde filling.
The totally occluded coronary sinus tributary was wired with the help of Crusade double lumen micro catheter. After wiring we had to perform balloon angioplasty of the venous stenosis for successful 4 Fr LV lead placement. We needed help of a IMA catheter and Attain sub elective catheter to increase the back-up support for successful passage of LV lead. Final position of the LV lead was optimum with good wide separation of the LV and RV leads. In 3 months follow up, his symptom improved to NYHA Class 1 on optimal medical therapy with LVEF of 35%. His QRSd in ECG is now 84 m sec.
The coronary vein stenosis are rare. Reported incidence is around 1.83%, with higher chances in post myocardial infarction and CABG patients. Stenosis and small-caliber veins can be successfully dilated with standard coronary angioplasty catheters without any intra operative or postoperative complications. Therefore, this option should always be explored before sending the patients for open surgical lead implantation.