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Left ventricular pacing via the great cardiac vein in a patient with tricuspid and pulmonary valve replacement

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A 63 year old female patient with carcinoid syndrome developed intermittent atrial flutter with complete heart block shortly after having a tricuspid and pulmonary valve replacement. Since both valves had been replaced by a Medtronic Hall mechanical tilting disc valve, it was not possible to insert a pacing lead into the right ventricle. Therefore, a unipolar, polyurethane coronary sinus lead was placed into the coronary sinus. After accessing the left cephalic vein, a guide catheter was introduced and placed into the ostium of the coronary sinus with the help of a movable tip ablation electrode. Then a venogram of the coronary veins was performed and the anatomy of the great coronary veins established. The pacing lead was inserted into the posterolateral cardiac vein. Fixation of the coronary sinus lead was achieved by angulation of the lead which occurred once the stylet was removed. Measurements at implant were: threshold at 0.5 ms was 0.4 V; R wave 17.1 mV; impedance at 5 V was 565 Ω.

The atrial lead was not implanted because of fears that electrode manipulation would displace the ventricular lead. A VVIR pacemaker was implanted and programmed to VVIR at 80–90 ppm.

A pacing check three days and two months post-implant showed low threshold, good R wave sensing, and stable impedance.