Feasibility of anchoring active fixation quadripolar lead to the main body of the dilated coronary sinus in a patient with persistent left superior vena cava: a case report.

Background: Coronary sinus (CS) lead placement in persistent left superior vena cava (PLSVC) cases is challenging because of the poor backup force of the guiding catheter within the enlarged CS. Active fixation Quadripolar leads (Attain Stability™ Quad 4798, Medtronic) can expand choice to CS branches with limited access; however, no cases of anchoring to the main body of the CS have been published to date.

Case summary: We describe a case of cardiac resynchronization therapy pacemaker upgrade in a 79-year-old female who developed pacing-induced cardiomyopathy after pacemaker implantation via the right superior vena cava (SVC) for atrioventricular block eight years ago wherein PLSVC was revealed during the procedure. Retrograde giant CS angiography via SVC confirmed the lateral vein ostium. Attain Stability Quadripolar lead was selected; however, due to the tortuousness and stenosis of the target vein, the proximal electrodes could not advance into the target vein. Therefore, the side helix between the third and fourth electrodes was crimped to the anterior wall of the giant CS using the distal end curve of the subselection catheter and successfully screwed into the main body of the CS. At more than 6 months, left ventricular ejection fraction improved without lead dislodgement.

Discussion: Fixation of CS lead to the main body of the dilated CS was feasible by devising a guiding catheter and a subselection catheter. Nevertheless, the safety of active fixation lead retraction after long-term indwelling in CS is unknown and it should be carefully considered.