Cardiac Resynchronization Therapy in Difficult Coronary Sinus Anatomy: Left Ventricular Endocardial Approach

To achieve cardiac resynchronization in a patient with severe ischemic cardiomyopathy with non-negotiable coronary sinus ostium.

A 260-cm coated 0.035-inch wire was advanced into the descending thoracic aorta through the left atrium and left ventricle after trans-septal puncture from the femoral venous route, which was then snared out through the right femoral artery. The other end of the wire was snared out from the left subclavian vein. A sheath with dilator was advanced over this wire to the left ventricular free wall. A thin, lumenless bipolar pacing lead was advanced through the sheath, implanted into the left ventricular lateral wall, and connected to the pulse generator.

The risk of thromboembolism and worsening mitral regurgitation are 2 major concerns; they may be avoided by using a thinner lead and strict anticoagulation.

Trans-septal left ventricular endocardial pacing using a thinner, lumenless lead is feasible, safe, and effective.