Femoral vein guidance for pipe-shaped coronary sinus cannulation and epicardial left ventricular lead placement using left subclavian vein approach

Variations in coronary sinus (CS) anatomy can make subclavian vein approach difficult or even impossible for LV lead delivery. A combination of interventional and electrophysiological methods is therefore the state of art technique for implantation of LV leads. A 52 year-old male patient with ischemic dilated cardiomyopathy (LVEF: 15%, QRS: 160 msec) who was symptomatic under optimal medical therapy was hospitalized for implantation of cardiac resynchronization therapy. Although right ventricular and atrial electrodes were implanted successfully, we had difficulty during placement of the left ventricular electrode. There was an anatomical variation in CS with a piped shape, which prevented cannulation from the superior approach. We describe a practical method for guidance of transfemoral route for pipe-shaped CS cannulation and epicardial placement of LV lead with superior approach.