title: Beyond coronary sinus angiography: the value of coronary arteriography and identification of the pericardiophrenic vein during left ventricular lead placement.
abstract: OBJECTIVE
  The purpose of this study was to define the role coronary arteriography (venous phase) for improving the success of left ventricular (LV) lead implantation and to define the value of identifying the pericardiophrenic vein for optimal LV lead placement in biventricular (bi-v) device implantation.
  
  
  METHODS
  Seventy-seven patients underwent bi-v device implantation between July 2002 and October 2003. If the coronary sinus (CS) could not be accessed, then left coronary arteriography was performed during the same procedure. CS access was guided by venous phase images of the coronary arteriogram. The pericardiophrenic vein was identified by selective cannulation or direct visualization. Patients with Cr > 1.5 had gadolinium used as the contrast agent.
  
  
  RESULTS
  Seventy-five successful implants were performed (97%). In seven patients (9%) repeated attempts at retrograde cannulation of the CS failed (attempt time 130 +/- 20 minute, mean +/- SD). In these patients, coronary arteriography helped define the location of the CS, which was subsequently successfully cannulated. In six patients the pericardiophrenic vein was identified either during occlusion venography of the CS (postthoracotomy, veno-venous collaterals, n = 2) or during selective cannulation of the pericardiophrenic vein (using a DAIG Csl catheter, n = 4). The vein was directly visualized in three patients who underwent surgical LV lead implantation. LV leads in all these cases were implanted in areas not overlying the preidentified pericardiophrenic vein. During follow-up, none of these patients had evidence of phrenic nerve stimulation.
  
  
  CONCLUSIONS
  Intraoperative left coronary arteriography increases the success of CS cannulation. Identification of the pericardiophrenic vein is a useful method to avoid phrenic nerve stimulation.
authors.affiliation: UCLA Cardiac Arrhythmia Center, Divisions of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1679, USA.
authors.forename: Marmar
authors.initials: M
authors.lastname: Vaseghi
authors.forename: David A
authors.initials: DA
authors.lastname: Cesario
authors.forename: Sen
authors.initials: S
authors.lastname: Ji
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Shannon
authors.forename: Isaac
authors.initials: I
authors.lastname: Wiener
authors.forename: Noel G
authors.initials: NG
authors.lastname: Boyle
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.forename: Miguel
authors.initials: M
authors.lastname: Valderrábano
authors.forename: Kalyanam
authors.initials: K
authors.lastname: Shivkumar
mesh_terms: D003287:Contrast Media; D017023:Coronary Angiography / Q000379:methods*; D019786:Gadolinium DTPA; D006352:Heart Ventricles; D006801:Humans; D010138:Pacemaker, Artificial; D015641:Radiography, Interventional; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000503:physiopathology / Q000628:therapy*
chemical_list: D003287:Contrast Media; D019786:Gadolinium DTPA