Maneuvering balloon occlusion technique to deflect LV lead into a target branch during CRT implantation

Implantation of specifically designed left ventricular (LV) lead is a relatively complex procedure that depends on the anatomy of the coronary veins, available instrumentation, and experience of the operator. In patients with dilated cardiomyopathy (DCM) tortuosity of the selected branch of coronary sinus (CS) leads to difficult or failed LV placement. A case study of a 45-year-old woman with DCM requiring lead placement is presented here. To plan for proper LV lead positioning, CS angiography was obtained through right femoral vein approach with preshaped long sheath (SJM, SL3) and occlusive balloon. For successful implant of LV lead, with no viable alternatives available, the tortuosity of the lateral and posterolateral branch were overcome by advancing and inflating the balloon in the main CS to deflect LV lead into the target branch. A unipolar LV lead (Medtronic 4193) was finally placed in a true posterolateral position with excellent sensing and pacing threshold without phrenic nerve stimulation.