213 Transseptal implantation of a left ventricular pacing lead for an ectopic location of the CS ostium in the left atrium

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The success rate of left ventricular (LV) lead implantation for cardiac resynchronization therapy (CRT) is high. Congenital abnormalities of the coronary sinus (CS) are rare but can be responsible for unsuccessful implantation. A 64-year-old male with standard indication for CRT was referred to our institution for a CRT-D implantation. Unfortunately, intubation of the CS was not possible. TEE showed a congenital CS anomaly with complete drainage of the CS into the left atrium. Because of contra-indication for general anaesthesia and thus for surgical epicardial implantation, we proposed to implant the LV lead by a transseptal approach. After the patient had given his consent, a transseptal puncture was performed via the right femoral vein. A conventional screw-in lead was implanted at the laterobasal segment of the LV using a deflectable catheter guide introduced via the left subclavian vein through the transseptal puncture. Post-implantation parameters of the LV lead were acceptable: pacing threshold 0.7 V-0.4 ms, impedance 435 ohms, R wave amplitude 5 mvolts. Right ventricular and right atrium leads were then implanted (fig 1) A post-implant CT scan confirmed the ectopic location of the CS ostium without persistent superior vena cava (fig 2). Figure 1 Figure 2 The patient was discharged on anticoagulation with a targeted international normalized ratio between 3 and 4. At the one- and three-month follow-up, no complication had occurred. He was in class 2 of the NYHA and had not been hospitalised. Electrical parameters remained steady. Complete drainage of the CS in the left atrium without persistent vena cava is a rare congenital abnormality. When cardiac resynchronization therapy is needed, transseptal implantation could be a feasible alternative.