Crossing the bends: Support-catheter based left ventricular lead placement in challenging cardiac resynchronization therapy device implantation

The combined use of an Amplatz guiding catheter and support catheter creates a progressively supportive rail to implant the left ventricular (LV) lead in difficult cardiac resynchronization therapy device implantation. We describe the case of a 32-year-old male with non-ischaemic cardiomyopathy, left bundle-branch block, and an LV ejection fraction of 30%, who was referred to our centre for a repeat attempt at an LV lead implant. Previously, the implanter had been unable to advance different guide catheters over the wire to the desired tributary of the coronary sinus (CS). At our centre, the CS was cannulated with a 6-Fr AL2 coronary guiding catheter. A 135-cm support catheter (Spectranetics Quick-Cross) was advanced via AL2 guiding over the 0.035 in. guide wire to the distal CS. The proximal luer fitting of the support catheter was cut and an inner sheath (Medtronic ATTAIN SELECT II) advanced over the support catheter into the CS. A 4-Fr over-the-wire LV lead was advanced through the inner sheath over a 0.014 in. percutaneous transluminal coronary angioplasty wire after removal of the support catheter. The use of a support catheter serves as rail for the placement of the inner sheath deep in the CS and facilitates implantation of the LV pacing lead. This technique is safe and easily applied.