B-PO05-048 INSERTION OF CORONARY SINUS LEAD UTILIZING INTRACARDIAC ECHOCARDIOGRAM, 3D ELECTRO-ANATOMICAL MAPPING, 3D PRINTED HEART MODEL AND FLUOROSCOPY IN A PATIENT WITH MARFAN SYNDROME AND PECTUS EXCAVATUM

Abstract

A 30-year-old woman with a history of pectus excavatum and Marfan syndrome s/p Bentall procedure 7 years prior developed complete heart block after aortic mechanical prosthesis and underwent PPM implant with one RA and two RV leads (RV apex and RVOT) in lieu of failed traditional CRT. She developed a reduced ejection fraction to 30% and was referred to our institution for CRT-D upgrade. Describe a case of CS lead insertion in a patient with complex anatomy. N/A CRT-P system and two RV leads were extracted using laser lead extraction. A CS lead could not be placed despite an extensive traditional approach. A cardiac CT was performed in order to better define CS anatomy, a 3D heart model was printed for procedural planning and CT images were merged with Carto 3D electro-anatomical system. Reviewing the model and images above, a significant cranial displacement of the CS ostium was noted with an acute angulation of the proximal CS. We proceeded with 3D anatomical mapping, ICE, and fluoroscopic guided insertion of a decapolar® catheter in CS via right femoral vein which was then exchanged for a glide wire in order to mechanically straighten the angulation in proximal CS. Then, using a long sheath from the left subclavian approach, the ostium of CS was engaged. The sheath was cautiously advanced under fluoroscopy and Carto mapping using a Bard quadripolar catheter. CS lead was inserted in a posterolateral branch with a recorded RV-LV separation of 150 msec. Multi-modality imaging and mapping can help insert CS leads in patients with prior unsuccessful attempts at cardiac synchronization therapy.