title: Implantable cardioverter defibrillator lead placement in the middle cardiac vein after tricuspid valve surgery.
abstract: OBJECTIVE
  Pacing and defibrillation with an implantable cardioverter defibrillator (ICD) after tricuspid valve surgery can be challenging if right ventricular (RV) lead placement is contraindicated or safe lead placement in the RV apex is impossible.
  
  
  RESULTS
  In six patients for whom RV lead placement and repeat thoracotomy were contraindicated, ventricular pacing and sensing were achieved with bipolar leads placed in the lateral branch of the coronary sinus or in the atrialized portion of the RV or without helix exposure of the pace-sense electrodes of the defibrillator leads. After cannulation of the middle cardiac vein (MCV), a defibrillator coil lead was delivered there and placed in the farthest apical position. An 'active can' pulse generator was implanted in the left retromammary region. Biphasic shocks were delivered between the MCV coil, SVC coil, and the 'active can', or between the MCV coil, azygous vein coil, and the 'active can'. All six patients underwent successful implantation. All patients had a defibrillation safety margin of at least 10 J (at least two successful shocks at 25 J). During follow-up, one patient received a successful internal shock for ventricular fibrillation, and two received successful overdrive ventricular pacing for ventricular tachycardia. Three patients underwent defibrillation threshold testing to evaluate safety margins. No late complications have been reported at 60 months' follow-up.
  
  
  CONCLUSIONS
  Defibrillator coil lead placement in the MCV is a safe alternative to epicardial lead placement via a thoracotomy in selected patients for whom RV lead placement is contraindicated or impossible.
authors.affiliation: Department of Cardiology and Electrophysiology,  Texas Heart Institute at St Luke's Episcopal Hospital and Baylor College of Medicine, 6624 Fannin Street, Suite 2780, Houston, TX 77030,  USA.
authors.forename: J Alberto
authors.initials: JA
authors.lastname: Lopez
mesh_terms: D000328:Adult; D000368:Aged; D000075202:Contraindications; D054326:Coronary Sinus / Q000000981:diagnostic imaging*; D017147:Defibrillators, Implantable; D004567:Electrodes, Implanted; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D006801:Humans; D008297:Male; D008875:Middle Aged; D010690:Phlebography; D019919:Prosthesis Implantation / Q000379:methods; D013908:Thoracotomy; D014262:Tricuspid Valve Insufficiency / Q000601:surgery*; D014693:Ventricular Fibrillation / Q000628:therapy*