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- ↵⁎Address for correspondence to:
Dr. Jeroen J. Bax, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
IN PATIENTS WITH CONGESTIVE HEART FAILURE DUE TO SYSTOLIC DYSFUNCTION WHERE ELECTRICAL AND MECHANICAL DYSSYNCHRONY IS PRESENT, cardiac resynchronization therapy has been shown to make patients “feel better” and “live longer” (1). In these procedures, left ventricular pacing is conventionally achieved via an endovascular approach by placing the lead in a coronary vein. Due to the marked variability in coronary venous anatomy, considerable difficulty can be encountered with this approach. Recent years have witnessed numerous investigations on the ability of imaging technology to delineate various aspects of coronary venous anatomy (2). We discuss the questions that go through the mind of the operator during the implantation procedure and illustrate how imaging technology, especially cardiac computed tomography and cardiac magnetic resonance (CMR), can help answer these questions, often even before the procedure.
Question 1. Are there congenital anomalies of the coronary venous system or of the thoracic veins present that the operator should be aware of?
Question 2. Will I be able to canulate the coronary sinus?
Question 3. After canulating the CS, can I advance the lead or sheath within the coronary venous system?
Question 4. Is it possible to find an appropriate venous branch?
Question 5. Will it be possible to obtain adequate left ventricular sensing and pacing threshold?
Question 6. What is the likelihood of diaphragmatic capture with the left ventricular pacing lead?
Conclusions. Cardiac imaging with MSCT scans or with CMR have the potential to be significantly beneficial by providing a roadmap before the procedure in patients undergoing resynchronization therapy. Especially in “problematic” patients, prior planning can make a significant difference, and imaging data can play a big role in preparation for the procedure. Cardiac imaging to guide device implantation is an area of active investigation and justifiably generates considerable excitement.
Dr. Krishnan has received lecture honoraria from Medtronic, St. Jude Medical, and Guidant, and has also received research support from Medtronic. Dr. Bax receives grants from Medtronic, Boston Scientific, BMS medical imaging, St. Jude Medical, GE Healthcare, and Edwards Lifesciences.
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