Case presentation: implantation of cardiac resynchronization therapy pacemaker via the coronary sinus in a patient with triple valve replacement

Abstract

BackgroundIn patients with triple valve replacement developing third-degree atrioventricular block (AVB), the most appropriate approach for permanent pacemaker implantation remains questionable.Case presentationIn this case presentation, we first described the approach of implantation of the cardiac resynchronization therapy pacemaker (CRT-P) via one bipolar pacing lead in middle cardiac vein (MCV) and one quadripolar pacing lead in anterior interventricular vein (AIV) in a patient developing complete AVB, who had been previously diagnosed with rheumatic valvular heart disease with triple valve replaced. After the CRT-P implantation, the two pacing leads in coronary sinus (CS) provided a dual-site ventricular pacing from the anterior septum and posterior septum, which resulted in a narrow QRS complex and an increased ventricular synchrony. During the long-term follow-up, no deterioration of heart function was documented and pacing parameters remained good.ConclusionIn this patient developing complete AVB with triple valve replaced, our approach of CRT-P implantation provides an effective and reliable ventricular pacing, and is an alternative option when transvenous right ventricular pacing, transseptal left ventricular pacing and transpericardial epicardium pacing are not possible. Further prospective randomized trials are required to confirm the efficiency of our approach of dual-site ventricular pacing by CRT-P in this kind patients.

Left Ventricle only single lead pacing in a patient with a tricuspid mechanical valve and a previous coronary sinus malfunctioning lead

“…The use of a single ventricular lead placed in the coronary sinus in patients with prosthetic tricuspid valves is well established. [1][2][3][4][5] Data shows that ventricular sensing by an LV lead placed in the coronary veins is feasible and reliable [7] . When compared to the unipolar leads, quadripolar leads have the advantage of having more pacing sites which can optimize the pacing threshold, [6] but the disadvantage of not allowing to perform conventional ventricular sensing, as it is usually achieved by the RV lead in patients with CRT-P.…”

“…[1][2] There are also described cases of dual-site ventricular pacing through the coronary sinus to cardiac resynchronization in patients with high pacemaker dependance and lower left ventricle (LV) ejection fraction. [3][4][5] Epicardial lead implantation may be an alternative but requires invasive surgical placement, making it a less ideal option in patients with a prior thoracotomy. Regarding single ventricle pacing with a CS lead, low sensing and unacceptable threshold at implantation can be an important issue, especially when using a conventional RV pacing lead.…”