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Snare technique: Selective cannulation of the posterior cardiac vein (black arrow). Guidewire advanced through the anterior collateral veins and anastomotic vein directly back to the PLSVC (white arrow). Snare system introduced through a second sheath via the LSV up to the PLSVC (black arrow). LSV: left subclavian vein; PLSVC: persistence of the left superior vena cava.
Source publication
Persistence of the left superior vena cava occurs in about 0.3-0.7% of the general population. It is of particular importance in patients who need cardiac resynchronisation therapy. We present a unique case in which a snare system and tunnelling tool were used to place the left ventricular lead in a patient with persistence of the left superior ven...
Similar publications
Persistence of the left superior vena cava occurs in about 0.3-0.7% of the general population. It is of particular importance in patients who need cardiac resynchronisation therapy. We present a unique case in which a snare system and tunnelling tool were used to place the left ventricular lead in a patient with persistence of the left superior ven...
Citations
Highlights
The article is a comprehensive literature review on anatomical variations and anomalies of cardiac veins. A classification of coronary venous anatomy and anomalies detailing clinical, anatomical and radiological features is proposed. Developing such classification is important for the field of left ventricular lead placement, as it would cover a variety of clinically significant anomalies of cardiac veins.
Abstract
With the advancements in the cardiac resynchronization therapy, the role of cardiac vein anatomy has become vital due to the complications associated with poor left ventricle lead placement. The cardiac vein anatomy varies much more than the anatomy of the coronary arteries, thus making cardiac veins much harder to study. In this article we have analyzed different approaches to description and naming of cardiac veins, and have summarized venous anomalies and features described in literature or encountered in real clinical practice. All anatomical features described in the article have a clinical significance in the left ventricle lead placement. Moreover, we have analyzed the wide variety of suggestions to overcoming anatomical obstacles. As a result of the analysis, we have proposed a clinical classification of the coronary venous anomalies and features that can be used during the implantation of cardiac resynchronization therapy devices.
Left ventricular lead positioning is technically demanding in cardiac resynchronization therapy (CRT) device implantation, especially in patients with complex cardiac venous anatomies. We report a case in which retrograde snaring was employed to successfully deliver the left ventricular lead through a persistent left superior vena cava for CRT implantation.
Background:
Left ventricular (LV) lead placement is the most challenging aspect of cardiac resynchronization therapy (CRT) device implantation, with a failure rate up to 10% due to complex coronary anatomies. We describe a modified snare technique for LV lead placement and evaluate its safety and efficacy in cases when standard methods fail.
Methods and results:
A prospective study was conducted of patients indicated for a CRT implant. When LV lead delivery to the target vessel failed using standard techniques, a modified snare technique was employed. Patients were evaluated every 6 months. From 2015-2019, 566 CRTs were implanted (26.1% female, 72±10.2 years old, follow-up duration 18.9±15.8 months). The standard LV implant technique failed in 94 cases (16.6%), of which the modified snare technique was successful in 92 (97.9%). There were no differences between the modified snare and standard techniques in the rates of 30-day post-implant CRT all-cause mortality (3.2% vs. 1.7%, p=0.33), 4-year all-cause mortality (15.9% vs. 15.5%, p=0.49), or major acute complications (7.4% vs. 3.8%, p=0.12). However, the 4-year procedural re-intervention rate was lower with the modified snare technique (3.2% vs. 10.2%, p<0.05), specifically LV implant failure or dislodgement rates (0% vs. 5.3%, p<0.05), improving the response rate (71.8% vs 55.1%, p<0.05).
Conclusions:
For challenging coronary sinus anatomies that preclude LV lead placement by standard methods, this modified snare alternative was safe and effective, with comparable mortality and complications, but significantly lower procedural re-intervention and higher response rates. This article is protected by copyright. All rights reserved.
