Upgrade from ICD to CRT-D in a patient with Persistent left superior vena cava using two valvuloplasty balloons in the Coronary sinus for LV lead placement

Background: A 65 year old male was transferred for evaluation for cardiac resynchronization therapy. A single chamber ICD had been implanted in 2009 after diagnosis of dilative cardiomyopathy. The patient had recently suffered from several cardiac decompensations and was currently NYHA status III. 12-lead-ECG revealed a complete left bundle branch block with a QRS duration of 206 ms. Transthoracic echocardiography showed reduced left ventricular ejection fraction (LVEF 32%). Past medical history was significant for paroxysmal atrial fibrillation, diabetes mellitus type II, arterial hypertension, hyperlipidemia, gout, hypothyroidism and chronic renal insufficiency.

Preoperative chest X-ray revealed an anomalous course of the ICD shock coil, suggestive of persistent left superior vena cava (PLSVC), which was confirmed by a contrast-enhanced CT.

Intervention: Intraoperatively, a venogram via a sheath in the left subclavian vein showed a grossly enlarged coronary sinus (CS). Due to the diameter of the enlarged CS and antegrade injection of contrast media, drainage into RA was too quick to opacify LV veins. To facilitate retrograde filling of possible target veins for LV lead placement, a 25 mm valvuloplasty balloon was introduced into the CS and inflated to hinder contrast drainage into the right atrium. Due to the large diameter of the CS, retrograde filling of LV veins could still not be achieved. Only after inflation of a second valvuloplasty balloon, drainage of contrast was slow enough to reveal a large posterolateral LV vein. One valvuloplasty ballon was retrieved, the other was positioned with its proximal end adjacent to the posterolateral sidebranch. Subsequently, the sidebranch was intubated successfully with a CS sheath and a 90° subselector, using the ballon's end as a "bumper" to guide the sheath from the CS into the vein. The ballon was retrieved, a wire was advanced throuh the sheath and a passive fixation quadripolar LV lead was implanted. After placement of an RA lead, the ICD was replaced with a CRT-D device and all three leads were connected with it.