Delivery of cardiac resynchronization therapy via the left inferior phrenic vein: a case report
Robert A McIntosh1,2, Mohammad I Ansari1, Joshua Moon1
1Trent Cardiac Centre, Nottingham University Hospitals, Hucknall Rd, Nottingham, UK.
Insights
Cardiac resynchronization therapy (CRT) can be challenging due to anatomical variations. Pacing through the left inferior phrenic vein (LIPV) offers an alternative when coronary sinus lead placement is not feasible.
Area of Science:
- Cardiology
- Medical Device Technology
- Interventional Electrophysiology
Background:
- Anatomical variations can impede successful cardiac resynchronization therapy (CRT) lead placement in the coronary sinus (CS).
- Difficulties include lead delivery failure, suboptimal capture thresholds, and phrenic nerve stimulation.
- Alternative left ventricular (LV) lead implantation methods carry significant morbidity risks.
Observation:
- A patient with ischemic heart disease and severe LV systolic dysfunction required CRT defibrillator implantation.
- Standard CS lead placement was not possible.
- Biventricular pacing was achieved by placing an LV lead through the left inferior phrenic vein (LIPV).
Findings:
- The LIPV provided satisfactory LV capture thresholds without significant diaphragmatic stimulation.
- The patient showed a marked clinical response with improved heart failure symptoms and LV ejection fraction post-implantation.
- The LIPV drains into the inferior vena cava in approximately one-third of individuals.
Implications:
- LV lead delivery via the LIPV presents a viable alternative route for CRT when CS access is not achievable.
- This technique may expand CRT eligibility for patients with challenging anatomy.
- Successful LIPV pacing demonstrates a potential to improve outcomes in heart failure management.
Background:
The successful implantation of cardiac resynchronization therapy (CRT) may be prevented by anatomical variations that preclude the delivery of clinically effective left ventricular (LV) pacing from within the coronary sinus (CS) or its tributaries. Failure of lead delivery, suboptimal LV capture thresholds, or intractable phrenic nerve capture with accompanying diaphragmatic twitch is often encountered. Commonly employed alternative approaches to LV lead delivery, including epicardial, trans-septal, or transapical pacing are associated with significant morbidity.
Case Summary:
A 74-year-old man with ischaemic heart disease, prior mitral valve repair, long-standing atrial fibrillation, and severe symptomatic LV systolic dysfunction, underwent single chamber pacemaker upgrade to a CRT defibrillator. It was found not to be possible to place a CS lead during the procedure. Biventricular pacing was accomplished by the delivery of a pacing lead through the left inferior phrenic vein (LIPV). Satisfactory LV capture thresholds were obtained with the avoidance of clinically significant diaphragmatic stimulation. Following implantation, a marked clinical response to treatment was observed with improvement in both heart failure symptoms and LV ejection fraction.
Discussion:
The LIPV is known to drain into the inferior vena cava in around one-third of examined subjects. In these individuals, LV lead delivery through the LIPV may provide an alternate route for the delivery of resynchronization therapy. This approach to the implantation of CRT may be considered when pacing via the CS or its branches are not achievable.
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