Preventing Inadvertent Cannulation Into the Vein of Marshall With a Useful Fluoroscopic Landmark

Coronary sinus (CS) injury is a potentially serious complication during left ventricular lead implantation. Its risk may be reduced by recognizing atypical guidewire trajectories.

A 71-year-old man with wild-type transthyretin cardiac amyloidosis underwent implantation of a cardiac resynchronization therapy device. During left ventricular lead placement, CS dissection occurred owing to the cannulation of a guiding catheter into the vein of Marshall (VOM) via an inadvertent guidewire. The patient remained hemodynamically stable, the CS dissection resolved spontaneously, and the procedure was completed successfully.

The VOM courses between the left atrial appendage and the left pulmonary veins. The third mogul, which corresponds to the left atrial appendage, may serve as a useful anatomical landmark to indicate inadvertent guidewire entry into the VOM.

Identifying the third mogul on anteroposterior fluoroscopic view could facilitate early detection of inadvertent guidewire entry into the VOM and help prevent coronary venous complications.