A 79-year-old man, previously diagnosed with ischemic heart disease and valve disease, who had undergone coronary artery bypass grafting and aortic valve replacement, was referred for implantation of a cardiac resynchronization system with defibrillator (CRT-D). He was in NYHA functional class III under optimized medical therapy, with left ventricular ejection fraction of 25%, mean QRS of 160 ms, and left bundle branch block.

After the coronary sinus was accessed, venography showed the target lateral vein (Figure 1). The guide wire was introduced up to the distal portion of the vein and the left ventricular lead was advanced, but the proximal region of the vessel could not be crossed. It was decided to advance the guide wire from the lateral vein via a posterior collateral vessel up to the coronary sinus ostium (Figure 2). A snare system was introduced through a sheath via the left subclavian vein up to the atrium (Figure 3A) and the end of the guide wire was gradually pulled towards the skin surface. Thus, both ends of the guide wire were under the operator's control (Figure 3B) and the lead could be advanced to the desired position by pulling the guide wire (Figure 4). CRT parameters were satisfactory without diaphragmatic stimulation. There were no complications.

Figure 1.

Venography showing the target lateral vein. SC: coronary sinus; Veia alvo: target vein.

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Figure 2.

Advancing the guide wire from the lateral vein via a posterior collateral vein up to the coronary sinus ostium (arrows).

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Figure 3.

(A) The snare system inside the atrium capturing the end of the guide wire; (B) both ends of the guide wire on the skin surface in two sheaths. Bainha no SC: sheath in the coronary sinus; Fio guia: guide wire.

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Figure 4.

Final position of the leads of the cardiac resynchronization system with defibrillator.

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Correct positioning of the left ventricular lead is crucial to a favorable response to CRT, but venous anatomy often hinders this goal, and alternative and sometimes technically challenging approaches must be adopted to obtain the greatest clinical benefit, as described here.