Balloon Venoplasty in Collateral-Assisted Venous Remodeling to Facilitate Left Ventricular Lead Delivery in Complex...

Optimal left ventricular (LV) lead placement is pivotal for the success of cardiac resynchronization therapy with defibrillator; however, tortuous, small, or sharply angulated coronary venous anatomy often frustrate standard delivery.

A 60-year-old woman with ischemic cardiomyopathy (ejection fraction: 23%) and NYHA functional class III symptoms was referred for cardiac resynchronization therapy with defibrillator implantation. A markedly narrowed, hairpin lateral vein prevented antegrade LV lead advancement. By exploiting a collateral from the middle cardiac vein into the lateral vein, we created a retrograde "through-and-through" rail that slightly straightened the bend; thereafter, multiple sequential balloon venoplasty of the collateral and target vein enlarged the lumen and enabled antegrade delivery of a quadripolar LV lead. Postimplant QRS duration narrowed from 160 to 120 milliseconds and symptoms improved to NYHA functional class II at 1 month.

Collateral-assisted retrograde wiring paired with multiple balloon venoplasty can safely remodel coronary sinus branches, transforming impassable anatomy into a navigable route for LV lead placement.

When hostile venous anatomy blocks antegrade LV lead delivery, opportunistic collateral wiring plus balloon venoplasty offers a safe, effective bailout by straightening bends and enlarging the vessel lumen.