Cardiac Resynchronization Therapy: Double Cannulation Approach to Coronary Venous Lead Placement via a Prominent Thebesian Valve

Abstract

We report identification of a prominent Thebesian valve by cardiovascular computed tomography (CT) angiography impeding cannulation of the coronary sinus, with subsequent successful coronary venous lead placement with cannulation of the coronary sinus ostium via a transvenous femoral vein approach and subsequent cannulation of the ostium with the coronary venous lead with a left subclavian approach. A 57-year-old man with nonischemic dilated cardiomyopathy, New York Heart Association Class III heart failure, left bundle branch block, and an ejection fraction of 15%, underwent an attempted cardiac resynchronization therapy implantable cardiac defibrillator (ICD). As the coronary sinus ostium could not be cannulated, a dual chamber ICD was placed. The patient subsequently underwent cardiovascular CT angiography, which identified a prominent Thebesian valve at the coronary sinus ostium as the anatomic obstacle to cannulation. Reattempted transvenous cardiac resynchronization therapy was accomplished successfully with a double cannulation approach: cannulation of the coronary sinus ostium with a catheter via a transvenous femoral vein approach and subsequent cannulation with the coronary venous lead via a left subclavian approach. When a prominent Thebesian valve is identified as an obstacle to transvenous left ventricular lead placement, cannulation of the coronary sinus by an alternate venous approach may allow for a coronary venous route rather than necessitate an epicardial approach.

The Thebesian valve and its significance for electrophysiologists

“…Of the patients undergoing invasive cardiac procedures, CS cannulation is unsuccessful in 5-10% of individuals, although Mak et al [11] believe that the incidence is underreported. Cao et al [3] reported a case of complicated implantable cardioverter-defibrillator procedure caused by a prominent Thebesian valve that required that implantation be made using an alternative venous approach due to the obstruction caused by the valve. Anh et al [2] visually examined the CS of 98 individuals during pacemaker implantation and observed a Thebesian valve in 54% of patients, with 6% of these having an ostium that was more than 70% covered by a huge valve.…”

Virtual medicine: Utilization of the advanced cardiac imaging patient avatar for procedural planning and facilitation

“…CCTA visualization of the coronary venous system allows for virtual preprocedure planning for facilitation of lead placement for cardiac resynchronization therapy. [186][187][188] Three-dimensional printing has also been used to assess the relationship between leads and other cardiovascular structures such as relationship of a His bundle Fig. 6.…”

Coronary venous system in cardiac computer tomography: Visualization, classification and role

“…It is situated at the base of the superior vena cava and sometimes is called the coronary sinus guard dog [36,37] . The valve may have a different size, shape or structure or it can be completely absent [38][39][40][41][42][43] . One of the largest researches that evaluated the Thebesian valve in autopsied hearts was presented in the paper by Mak et al [36] .…”