The use of a lumenless tip-fixation lead in coronary vein.

Abstract

Case presentation A 78-year-old female patient had history of chronic rheumatic heart disease and symptomatic sick sinus syndrome. She was treated with mechanical mitral and tricuspid valve replacement with epicardial pacemaker implantation in year 2003. Epicardial pacemaker generator change was performed in year 2012. There was gradual increase in left ventricular (LV) lead threshold to 3.0 V/0.52 ms. Second pacemaker generator change was attempted in year 2017 but was complicated with significant wound haematoma formation. Eventually removal of epicardial generator was required. The epicardial leads were capped off. Patient declined epicardial lead revision given the risk associated with pericardial access with the expected adhesion following surgery. We proceeded for transvenous pacing through branches of coronary sinus (CS). Unfortunately, balloon occlusive venogram showed absence of posterolateral branch of adequate size to accommodate pacing lead (Figure 1A). A bipolar LV lead with circumferential fixation feature (Attain Stability 20066, Medtronic Inc.) was placed at several positions in the septal branches (Figure 1B); however, there was no capture at all the sites tested at the highest output. We then attempted His-bundle pacing (SelectSecure model 3830, Medtronic Inc.) supported with delivery sheath (C315His, Medtronic Inc.). However, owing to the large right atrium size (max 8.1 cm length on computer tomography), we were unable to position the pacing lead near the His-bundle region to achieve direct or indirect His-bundle pacing. After