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How to Manage a Coronary Sinus Dissection and Complete the CRT Implantation (Presenter: Amin Al-Ahmad, MD, FHRS, CCDS)
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Video Transcription
Great. Well, thank you very much. Let's see if we can start. This could be a very fast talk. Okay, here we go. So how do we manage a coronary sinus dissection and finish up our implant? As you all know, CRT improves mortality in select patients. However, you need access to the coronary sinus, and in some cases it can be a challenge to get into the coronary sinus. Dissection of the CS can occur and will occur, and in some cases can limit your success. So there has to be some strategies in terms of managing it. So one question is how common is it? How often do we see CS dissection? And the reality is it's not very common. There's some early single-center studies that show 4% dissection in miracle care, 2% dissection, some single-center ones that are 4%. But more recently, the NCDRI database suggests a much lower percent. However, what's not clear is how well or how granular that data is. That seems to be awfully low. It seems, interestingly, in the NCDRI data, more common in women and a little bit more common in patients with the left bundle, whether that's related to the size of the heart or the atrium is not entirely clear. So here's a case. Can it limit your ability to get a successful implant? So this is a case that I found from our center where somebody is trying to get into the coronary sinus and using puffs of contrast, which is a common technique, using a sheath. And unfortunately, what happens in this case is they dissect the coronary sinus. Now, a couple of things I'd point out. If you look on this video, you start to see a little bit of contrast just there on the outside surface of the heart. So in addition to dissecting the coronary sinus, there's probably a perforation. It turns out that dissections and perforations happen together, not uncommonly. I've got to figure out how to manage this video thing. So he tried to get through with the wire and then ultimately gave up. And this is the final image, and you can see that there was that little bit of contrast just outside the heart. Well, why do we see dissections? There's a bunch of reasons, and some of it may be related to some of the anatomy. This is from a study we did years ago where we looked with a camera at the osso of the coronary sinus, and we saw all sorts of valves and fenestrations and things like that. And you can imagine that at times your catheter may get stuck in these or get stuck in a small branch, and you can have a dissection. There's other reasons for dissection that are related to technique, and we'll talk about some of those as well. Here's another image that shows some of this. So some of these can actually be quite difficult to pass, and as you push hard or eject, you might end up with a little bit of a dissection. In addition to that, sometimes the coronary sinus is very, very small, and sometimes you get spasm of the coronary sinus, all of which can lead to you having a dissection. And again, associated often with perforation of the coronary sinus and some contrast outside the surface. Now, in these types of cases, it's really an issue. If you see this, it's not a big deal. Stay calm. Just look at the silhouette of the heart, and just look at that contrast as it's there. If that contrast disappears, then you may be having a problem, but for the most part, it's not really an issue. It doesn't really typically impact your ability to succeed in the case. This is a case of mine. I'm a little bit ashamed to show it, but I'll show it anyways. This is a case of a pneumopericardium after an implant, and this is the only one I've ever seen. This patient had chest pain after the procedure. We did an X-ray and found air in the pericardial sac, and, of course, I blamed the fellow because he must have made an injection that was too hard, dissected the coronary sinus, got air in there somehow. But, again, this patient did just fine and really not an issue. So here's a second case. This is a patient where we dissect the coronary sinus here, and the reason here is there's just a little branch, and it looks like the sheath just really likes getting to that little branch. Here it goes again. You can try to see here that the sheath just really dives down into that branch, and when it does that and you give a good injection, you will dissect. Now, the way to get through that, and, of course, you also note that the majority of coronary sinus dissections are typically in the first third of the coronary sinus. Now, the way to get across this is typically a wire, very easy to just take a soft wire, usually an angled glide that's soft, and it'll pass right beyond that without any difficulty. And you can generally have a successful implant with this as long as you pass it. Now, one thing to remember is if you do pass it and you're going to start advancing your lead, that you need to remember not to let the sheath pull back and back into that dissection flap, so you want to just have your system not do that. A very common area to dissect is in that vein of martial area. This is an example of that, and so this is kind of what not to do. Typically here, you see a little bit of contrast, and then for whatever reason, the operator advances the balloon and gives another good injection and essentially dissects that vein of martial. And the best way to do this is very obvious. Once you get the tip of the balloon to the tip of the sheath, just pull back the sheath and inflate your balloon, and give a little bit of puff of contrast that can tell you if you're stuck in a branch or something like that. Another way you could do it is you could, so if you do in fact do that, you can always still pass this. This is not a big deal. Typically what you want to do is just get your wire beyond the dissection, and once you've done that, you're pretty much home free. Occasionally the lead will stick up on it a little bit, but generally speaking, this is not a big deal and shouldn't really limit your ability to deliver the lead. This is an example, again, of what not to do. So you see how that balloon just shot out, and this operator got pretty lucky with that one. Here it is again. I'll show it to you again. So again, just careful technique by remembering to pull the sheath back rather than the balloon forward is always helpful. You can also advance the balloon over a wire, that sometimes helps, and of course you can inject with the sheath by itself without a balloon. In some coronary sinuses that's very adequate. If you use a good solid full dose contrast, you're usually fine with that as well. What are some of the outcomes? This is from an old study. This is an interesting study because this was back in 2004, where when they saw a dissection, this group stopped. They didn't do anything else. They said, we have a dissection, we're going to get out, and then we're going to come back and see what happens later. So seven patients with CS dissections. They aborted the implant, all of them near the coronary sinus, which is often what you see with these types of patients, and at 45 days only one patient had some type of irregularity there. I don't think that's a strategy of anybody anymore. In fact, if we do dissect, we typically just continue with the case. There is a small amount of data with this. This is data from Cleveland Clinic between 2001 and 2018. They noted CS dissection at 0.6%, and the majority of the dissections, about 80%, still able to complete the implant. One patient had tamponade, which, again, is very unusual. But, again, if you do see a dissection, you will sometimes note some contrast in the pericardial sac. So I'll conclude. Dissection is relatively uncommon. There are simple technique adjustments that you can do that will lead to a decrease in dissection. Lead delivery is very likely and possible after a coronary sinus dissection, and occasionally it's associated with small effusions, but these are essentially minor issues, and you can still continue with your implant with that. With that, I thank you. Thank you, Farron. That was excellent. We have time for questions. So clearly there are different ways of implanting CS leads, and you showed some nice pictures of a sheath alone, of a sheath with an EP catheter, although you weren't using it in one of the dissections. Any feel amongst any of you in terms of is there a difference in dissection rate between those people who use preformed sheaths and a glide wire or a guide wire and those who use an EP catheter and those who use a sheath alone? Yeah, there is no data on that. Actually, in order to prepare for this talk, I went through our archive. We archive just about every case. I looked at all of our CRT cases over the last couple of years to find examples of dissection. The good news is we don't dissect a lot, so that's kind of good at our center. And then I thought I would see more with catheter delivery. We didn't. In fact, it seemed like I saw more with just a sheath and some contrast, but, you know, I can't really make much out of the numbers. They're pretty small. I see Seth out in the audience. He's the maestro of the coronary sinus, so maybe he has some comments. I was waiting for him to come. Seth, I used full-dose contrast. I'm sorry to bring this up. I've seen my concern that when I see dissections, it's usually when somebody puts a wire into the vein of Marshall, and then they think that it's in the coronary sinus, and if you follow over that wire, like with a balloon, and think that the old saw is if you put a balloon up over a wire, then it's safe. I think that's really dangerous because if you put the wire, it's very easy for the wire to get into the corner into the vein of Marshall. You put the balloon up over the wire, and then you blow the balloon up without checking, and then you can rip the vein of Marshall and get a nice dissection. In that same, along those same lines, if you're putting a wire up and you want to advance your sheath, it's easy for the wire to get into the vein of Marshall. And unless you're cognizant of the, if you see the wire stop, you need to remember that that's not the coronary sinus. That's the vein of Marshall. I proctor cases a lot around the world, and I've seen people, you know, they put a wire up, they say, well, it's in the coronary sinus, and they jam the sheath in, and it's actually jamming into the vein of Marshall. And then that leads to the EP catheter, which I've only seen really serious dissections with EP catheters, and I never really understood why, but I think that if you get an EP catheter and you put it into the coronary sinus and you do an EP study and it just happened to be in the vein of Marshall the whole time, nothing happens, right? It's fine and it's safe, but if you use that same EP catheter and happen to get it into the vein of Marshall and then you follow it up with a sheath, then you rip the vein of Marshall. So the ones that I've seen have been where the EP catheter gets into the vein of Marshall and then you slide your sheath over the EP catheter and then rip the vein of Marshall. And unlike a wire, you can't tell. With a wire, you can see that it stops and then you can bring it back and then you can get the wire to go out, but with an EP catheter, it's really hard to tell that it's not in the vein of Marshall or is in the vein of Marshall, unless you go LAO, RAO and all that. I mean, I think your experience obviously is incredible in this area. In fact, absolutely, the dissections are typically from the os to the vein of Marshall. That's sort of the dissection alley. And vein of Marshall is a very common area for dissection, exactly for the reasons that you described. And it's easy to, you know, unfortunately people do make that mistake. That example I showed, you know, the first puff was fantastic, but the person decided to advance the balloon right into the vein of Marshall and dissect. The good news is, for the most part, you can still get beyond this and finish your case, as I'm sure, you know, you never have a dissection, but I, you know, when I do, I can usually finish my case, but. And the other thing is the Duesen's valve tends to deflect it. The Duesen's valve is here, the vein of Marshall is right below it, and the valve tends to deflect stuff into the vein of Marshall, so that it really does represent a pitfall for causing dissections. Yeah, thank you. Thank you. Thanks.
Video Summary
The speaker discusses the management of coronary sinus dissection during cardiac resynchronization therapy (CRT) implantation. CRT improves mortality in select patients, but accessing the coronary sinus can be challenging. Dissection of the coronary sinus can occur, limiting success. Data on the frequency of dissection is not clear, but it is more common in women and patients with left bundle branch block. The speaker presents case examples of dissection and explains various strategies for managing it. While dissections can occur, they typically do not impact the ability to successfully deliver the lead for CRT.
Meta Tag
Lecture ID
12419
Location
Room 155
Presenter
Amin Al-Ahmad, MD, FHRS, CCDS
Role
Invited Speaker
Session Date and Time
May 10, 2019 4:30 PM - 6:00 PM
Session Number
S-088
Keywords
coronary sinus dissection
cardiac resynchronization therapy
CRT implantation
mortality improvement
accessing coronary sinus
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