Author + information
- Received October 29, 2018
- Revision received November 5, 2018
- Accepted November 15, 2018
- Published online March 18, 2019.
- aDepartment of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
- bDepartment of Cardiology, Ludwig Maximilian University, Munich, Germany
- ↵∗Address for correspondence:
Dr. Florian Herrmann, Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Marchioninistrasse 15, 81377 Munich, Germany.
- cardiac anatomy
- cardiac resynchronization therapy
- congenitally corrected transposition of the great arteries
- left ventricular lead
Patients with congenitally corrected transposition of the great arteries typically initially present with atrioventricular block or heart failure as adults. The corrected transposition leads to a double discordance—discordance of the atrioventricular connection and ventriculo-arterial connection leading to a physiological circulation of the blood. Our patient initially presented with syncope. After diagnosing a third-degree heart block as well as congenitally corrected transposition of the great arteries and situs inversus, the patient underwent dual-chamber pacemaker implantation from the left side. One year after pacemaker implantation, our patient underwent an upgrade to a cardiac resynchronization therapy defibrillator after developing progressive heart failure under constant ventricular pacing (functionally right/morphologically left ventricle). Before implantation of the cardiac resynchronization therapy defibrillator, we ordered computed tomography with angiography of the thoracic veins to gain a better understanding of the venous anatomy. To improve access to the coronary sinus we chose to switch the implant site from the left to the right. A new right atrial lead was placed in the morphologically right atrium and the single coil right ventricular defibrillator lead was placed in the functionally right/morphologically left ventricle via the right subclavian vein and left-sided superior vena cava. Fluoroscopy showed that the veins available for left ventricular lead placement all developed from the coronary sinus in a cranial orientation (Figure 1, Online Video 1). Using an extended hook sheath, a quadripolar lead was placed in an appropriate “posterolateral vein” of the functionally left/morphologically right ventricle (Figure 1). In this complex case, we accepted a higher left ventricular pacing threshold value: 2.0 V/1.0 ms; the resistance was 440 Ω. Due to the lack of a ventricular rhythm, the sensing could not be tested. The duration of the complete procedure was 127 min; fluoroscopy time was 8 min, 12 s. To improve cardiac resynchronization therapy device implantation success, we advocate for pre-operative planning via computed tomography angiography in cases with complex cardiac anatomy.
Dr. Fichtner has received lecture fees from Medtronic. All other authors have reported that they have no relationships relative to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received October 29, 2018.
- Revision received November 5, 2018.
- Accepted November 15, 2018.
- 2019 American College of Cardiology Foundation