title: Use of a modified introducer sheath with a side-hole to improve access to left ventricular veins with proximal origin.
abstract: OBJECTIVE
  Despite technical advances in tools used to facilitate implantation of cardiac resynchronization therapy (CRT) devices, there are many hurdles related mainly to the variation in the anatomy of the coronary veins. One such difficulty is the presence of a very proximal origin of the lateral or postero-lateral cardiac vein.
  
  
  RESULTS
  We describe an alteration of existing left ventricular (LV) lead delivery sheath with the creation of a side-hole 35-50 mm from its tip. This modification is made to provide access to proximal cardiac vein ostia, while maintaining adequate support for the delivery system. The modified introducer sheath was used in the implantation of six CRT systems (four defibrillators and two pacemakers) in patients who had a proximal origin of the lateral or postero-lateral cardiac vein, all of which were successful and without complications.
  
  
  CONCLUSIONS
  In those patients with unusual proximal origin of target LV veins, modifications of the introducer sheath with the creation of a side-hole facilitate the successful implantation of the LV pacing lead. Until this modified sheath is tested, this technique is considered experimental and may carry unknown risks.
authors.affiliation: Department of Adult Cardiology Prince Sultan Cardiac Center, PO Box 7897, X-982, Riyadh 11159, Saudi Arabia. avnrt@hotmail.com
authors.forename: Ayman S
authors.initials: AS
authors.lastname: Al-Khadra
mesh_terms: D006328:Cardiac Catheterization / Q000295:instrumentation*; D003331:Coronary Vessels; D017147:Defibrillators, Implantable; D005260:Female; D006352:Heart Ventricles; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial