title: Introducer Development for Coronary Sinus Access From Parasternal Mediastinotomy.
abstract: OBJECTIVE
  Right parasternal mediastinotomy with right atriotomy has been used clinically for pacemaker insertion. A similar approach might facilitate access to the coronary sinus for biventricular pacing and other manipulations when more conventional approaches are not feasible. The primary barrier to this is lack of appropriate introducers and techniques.
  
  
  METHODS
  Anatomically derived introducers were developed in 2 anesthetized domestic pigs using data from computerized axial thoracic tomography. Each digitized tomogram defined a unique introducer shape and was constructed using 3-dimensional (3D) modeling software and printing. Each parent pig then underwent surgery demonstrating coronary sinus lead insertion, using its custom-configured introducer. Next, with institutional review board approval, 65 patients were identified who had undergone conventional endocardial coronary sinus lead insertion followed by thoracic scanning. These tomograms were used to design appropriately curved introducers for human anatomy.
  
  
  RESULTS
  Fifty-one introducer paths were defined following anatomic pathways and avoiding bends inconsistent with materials used for commercial peel-away introducers. Each path was defined by a bend and distance toward the coronary sinus ostium and a hook and twist out of plane to align with the local orientation of the coronary sinus. The average dimensions were the following: distance, 67 mm; bend angle, 47 degrees; hook angle, 39 degrees; and twist angle, 20 degrees. A prototype cannula was tested for fit in a fresh frozen postmortem human specimen.
  
  
  CONCLUSIONS
  Parasternal mediastinotomy access to the coronary sinus for cardiac resynchronization, mitral annuloplasty, and instrumentation is feasible. Human computerized tomographic scans can be used to define curvatures and dimensions for marketed introducers.
authors.affiliation: From the Departments of *Surgery, †Biomedical Engineering, ‡Medicine, and §Radiology, Columbia University, New York, NY USA.
authors.forename: Henry M
authors.initials: HM
authors.lastname: Spotnitz
authors.forename: Keith J
authors.initials: KJ
authors.lastname: Yeager
authors.forename: Santos E
authors.initials: SE
authors.lastname: Cabreriza
authors.forename: Gordana
authors.initials: G
authors.lastname: Vunjak-Novakovic
authors.forename: Daniel Y
authors.initials: DY
authors.lastname: Wang
authors.forename: Gregory D N
authors.initials: GD
authors.lastname: Pearson
mesh_terms: D000818:Animals; D058406:Cardiac Resynchronization Therapy / Q000379:methods; D054326:Coronary Sinus / Q000033:anatomy & histology* / Q000601:surgery*; D006325:Heart Atria / Q000601:surgery; D006801:Humans; D021621:Imaging, Three-Dimensional; D008482:Mediastinum / Q000033:anatomy & histology / Q000601:surgery*; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation / Q000379:methods; D058386:Mitral Valve Annuloplasty / Q000295:instrumentation / Q000379:methods; D023421:Models, Animal; D013249:Sternum / Q000033:anatomy & histology / Q000601:surgery*; D013552:Swine; D014057:Tomography, X-Ray Computed