Challenging coronary sinus lead placement for CRT: A modified "Anchoring balloon" technique

An 80-year-old man with a history of complete heart block underwent dual chamber pacemaker implantation about a year ago. He returned to the hospital due to de novo heart failure caused by pacing-induced cardiomyopathy; hence, we planned to upgrade his pacemaker to a biventricular device. The initial strategy was to perform left bundle branch area pacing-optimized cardiac resynchronization therapy (LOT-CRT) with left bundle branch area pacing (LBBAP) combined with a coronary sinus (CS) lead. In this challenging case, the successful placement of a CS lead was hindered by a complicated combination of a large CS body linked to the left superior vena cava and a winding CS branch. However, utilizing readily available tools, such as the coronary balloon and Guide Plus II ST catheter, proved instrumental in overcoming these obstacles. As a result, LOT-CRT provided the patient with a safe alternative to surgical LV lead placement.