case_images: PMC9280357_01
case_images: The Lee's venogram balloon catheter (6F-11 mm-CS) with coronary sinus shaping, has an open lumen, over-the-wire design, which tracks over the guidewire and allows access to any site of the coronary vein system. Schematic diagram of the Lee's venogram balloon with: balloon inflation port and guidewire port for access to central lumen.
case_images: fcvm-09-892122-g001.jpg
case_images: PMC9280357_01_fcvm-09-892122-g001.jpg
case_images: F1
case_images: The LV electrode was successfully deployed via Lee's venogram balloon catheter according to the above implant procedure steps (Figure 2 and Video 1).
case_images: (A) Lee's venogram balloon catheter advanced through the 9 French CS sheath lumen to the CS ostium. (B) Radifocus guidewire was successfully cannulated into the coronary sinus through Lee's venogram balloon central lumen. (C) The Radifocus guidewire is advanced to the distal CS and used to advance the inner guide and 9 French CS sheath into the CS. (D) Lee's venogram balloon occlusion angiogram of the CS in anteroposterior projection. (E) The advance runthrough-NS floppy guidewire into target vein along Lee's venogram balloon lumen. (F) Once the guidewire is into the target branch, the Lee's venogram balloon is removed and the LV lead is advanced over the guidewire.
case_images: fcvm-09-892122-g002.jpg
case_images: PMC9280357_02_fcvm-09-892122-g002.jpg
case_images: F2
case_images: In this patient, the desired vein had an acute angle of take-off, which made it difficult to access (Figure 3A and Video 2). The positioning of this second guidewire against the vein's wall effectively reduced the acuteness of the angle of the side branch, which permitted the over the-wire LV to be further advanced over the guidewire to reach a stable pacing position (Figure 3B and Video 2).
case_images: PMC9280357_02
case_images: (A) Lee's venogram balloon catheter advanced through the 9 French CS sheath lumen to the CS ostium. (B) Radifocus guidewire was successfully cannulated into the coronary sinus through Lee's venogram balloon central lumen. (C) The Radifocus guidewire is advanced to the distal CS and used to advance the inner guide and 9 French CS sheath into the CS. (D) Lee's venogram balloon occlusion angiogram of the CS in anteroposterior projection. (E) The advance runthrough-NS floppy guidewire into target vein along Lee's venogram balloon lumen. (F) Once the guidewire is into the target branch, the Lee's venogram balloon is removed and the LV lead is advanced over the guidewire.
case_images: fcvm-09-892122-g002.jpg
case_images: PMC9280357_02_fcvm-09-892122-g002.jpg
case_images: F2
case_images: In this patient, the desired vein had an acute angle of take-off, which made it difficult to access (Figure 3A and Video 2). The positioning of this second guidewire against the vein's wall effectively reduced the acuteness of the angle of the side branch, which permitted the over the-wire LV to be further advanced over the guidewire to reach a stable pacing position (Figure 3B and Video 2).
case_images: Coronary sinus venogram (A) and fluoroscopic images identifying the sharply angulated posterolateral branch of the coronary sinus (B) and the placement of the LV pacing lead using the double wire technique (C) (see text for details).
case_images: fcvm-09-892122-g003.jpg
case_images: PMC9280357_03_fcvm-09-892122-g003.jpg
case_images: F3
case_images: Using Lee's venogram balloon catheter, these difficulties can be easily overcome with the support of a Radifocus guidewire (Terumo Co., Japan) (Figure 4A and Video 3). The venogram showed a very angulated anterolateral side branch (Figure 4B and Video 3). Lee's venogram balloon catheter subselectively entered the anterolateral side branch along the Radifocus guidewire (Figure 4C and Video 3). Another runthrough-NS floppy guidewire was inserted into the anterolateral branch as a second wire to attempt to straighten the angle of the vessel (Figure 4D and Video 3).
case_images: PMC9280357_03
case_images: Coronary sinus venogram (A) and fluoroscopic images identifying the sharply angulated posterolateral branch of the coronary sinus (B) and the placement of the LV pacing lead using the double wire technique (C) (see text for details).
case_images: fcvm-09-892122-g003.jpg
case_images: PMC9280357_03_fcvm-09-892122-g003.jpg
case_images: F3
case_images: Using Lee's venogram balloon catheter, these difficulties can be easily overcome with the support of a Radifocus guidewire (Terumo Co., Japan) (Figure 4A and Video 3). The venogram showed a very angulated anterolateral side branch (Figure 4B and Video 3). Lee's venogram balloon catheter subselectively entered the anterolateral side branch along the Radifocus guidewire (Figure 4C and Video 3). Another runthrough-NS floppy guidewire was inserted into the anterolateral branch as a second wire to attempt to straighten the angle of the vessel (Figure 4D and Video 3).
case_images: (A) In the case of obvious enlargement of the right atrium, the Radifocus guidewire can be easily cannulated into the CS guided by Lee's venogram balloon. (B) Lee's venogram balloon CS venography showed acute angled anteriolateral veins. (C) Radifocus guidewire subselectively entered the anterolateral side branch. (D) Lee's venogram balloon catheter subselectively entered the anterolateral side branch along the Radifocus guidewire. (E) After withdraw the Radifocus guidewire, double guidewires subselectively entered the anterolateral side branch along the Lee's venogram balloon. (F) LV lead is advanced into anteriolateral veins over the guidewire.
case_images: fcvm-09-892122-g004.jpg
case_images: PMC9280357_04_fcvm-09-892122-g004.jpg
case_images: F4
case_images: RA, a Lee's venogram balloon catheter inside a conventional guide catheter extends the reach of the system and directs a guidewire or contrast injection superiorly toward an upwardly angulated CS (Figure 5A and Video 4). Radifocus guidewire subselected lateral side branch via Lee's venogram balloon catheter after CS venogram (Figure 5B and Video 4). The catheter was also subselected along the guidewire into the lateral side branch, and then the guidewire was withdrawn (Figure 5C and Video 4). The St Jude Quartet Model 1458Q quadripolar LV lead was subsequently advanced over the wire into the lateral side branch (Figure 5D and Video 4).
case_images: PMC9280357_04
case_images: (A) In the case of obvious enlargement of the right atrium, the Radifocus guidewire can be easily cannulated into the CS guided by Lee's venogram balloon. (B) Lee's venogram balloon CS venography showed acute angled anteriolateral veins. (C) Radifocus guidewire subselectively entered the anterolateral side branch. (D) Lee's venogram balloon catheter subselectively entered the anterolateral side branch along the Radifocus guidewire. (E) After withdraw the Radifocus guidewire, double guidewires subselectively entered the anterolateral side branch along the Lee's venogram balloon. (F) LV lead is advanced into anteriolateral veins over the guidewire.
case_images: fcvm-09-892122-g004.jpg
case_images: PMC9280357_04_fcvm-09-892122-g004.jpg
case_images: F4
case_images: RA, a Lee's venogram balloon catheter inside a conventional guide catheter extends the reach of the system and directs a guidewire or contrast injection superiorly toward an upwardly angulated CS (Figure 5A and Video 4). Radifocus guidewire subselected lateral side branch via Lee's venogram balloon catheter after CS venogram (Figure 5B and Video 4). The catheter was also subselected along the guidewire into the lateral side branch, and then the guidewire was withdrawn (Figure 5C and Video 4). The St Jude Quartet Model 1458Q quadripolar LV lead was subsequently advanced over the wire into the lateral side branch (Figure 5D and Video 4).
case_images: (A) After the right axillary venous puncture, the CS cannulation catheter (CPS Direct  PL Peelable Outer Guide Catheter ST-JUDE) was guided through the Lee's venogram balloon catheter to the CS ostium, and then the CS was cannulated in the left anterior oblique position by passing the Radifocus guidewire through the Lee's venogram balloon. (B) Upon cannulation of the CS, the CS sheath is advanced over the Lee's venogram balloon into the CS. Then, a coronary venous angiogram is obtained with contrast injection to delineate the venous anatomy and select the target vein (arrow). (C,D) After the Radifocus guidewire was subselected to enter the target vein, Lee's venogram balloon catheter enters the target vein along the Radifocus guidewire. Lee's venogram balloon catheter was then withdrawn. (E,F) After proceeding the double wires to the target branch, the LV lead was finally delivered to the lateral branch over the wire.
case_images: fcvm-09-892122-g005.jpg
case_images: PMC9280357_05_fcvm-09-892122-g005.jpg
case_images: F5
case_images: The CS venogram via Lee's venogram balloon catheter showed a very angulated and tortuous target vein (inferolateral side branch) (Figure 6A and Video 5). One runthrough-NS floppy guidewire (Terumo) was sent through Lee's venogram balloon catheter to the great cardiac vein for anchoring and then through Lee's venogram balloon catheter into the second runthrough-NS floppy guidewire (Terumo) to the target vein (Figure 6B and Video 5). Using this "double wire technique," tortuosities in the target branch are straightened, allowing uninhibited lead advancement (Figure 6C and Video 5). By keeping both wires in the side branch, a wire that is positioned against the wall of the vein can decrease the sharp angle, permitting the over the wire LV lead (Quartet 1458Q, St Jude Medical) to be finally delivered to the inferolateral branch over the other guidewire (Figure 6D and Video 5).
case_images: PMC9280357_05
case_images: (A) After the right axillary venous puncture, the CS cannulation catheter (CPS Direct  PL Peelable Outer Guide Catheter ST-JUDE) was guided through the Lee's venogram balloon catheter to the CS ostium, and then the CS was cannulated in the left anterior oblique position by passing the Radifocus guidewire through the Lee's venogram balloon. (B) Upon cannulation of the CS, the CS sheath is advanced over the Lee's venogram balloon into the CS. Then, a coronary venous angiogram is obtained with contrast injection to delineate the venous anatomy and select the target vein (arrow). (C,D) After the Radifocus guidewire was subselected to enter the target vein, Lee's venogram balloon catheter enters the target vein along the Radifocus guidewire. Lee's venogram balloon catheter was then withdrawn. (E,F) After proceeding the double wires to the target branch, the LV lead was finally delivered to the lateral branch over the wire.
case_images: fcvm-09-892122-g005.jpg
case_images: PMC9280357_05_fcvm-09-892122-g005.jpg
case_images: F5
case_images: The CS venogram via Lee's venogram balloon catheter showed a very angulated and tortuous target vein (inferolateral side branch) (Figure 6A and Video 5). One runthrough-NS floppy guidewire (Terumo) was sent through Lee's venogram balloon catheter to the great cardiac vein for anchoring and then through Lee's venogram balloon catheter into the second runthrough-NS floppy guidewire (Terumo) to the target vein (Figure 6B and Video 5). Using this "double wire technique," tortuosities in the target branch are straightened, allowing uninhibited lead advancement (Figure 6C and Video 5). By keeping both wires in the side branch, a wire that is positioned against the wall of the vein can decrease the sharp angle, permitting the over the wire LV lead (Quartet 1458Q, St Jude Medical) to be finally delivered to the inferolateral branch over the other guidewire (Figure 6D and Video 5).
case_images: (A) CS venography by Lee's venogram balloon showed that the target vessel ostium was low, sharply angled, and close to the CS ostium. Without runthrough-NS floppy guidewire anchorage, the CS sheath was easy to prolapse out of the CS. (B) One runthrough-NS floppy guidewire was sent to the great cardiac vein via Lee's venogram balloon for anchoring. (C,D) The positioning of the second guidewire through Lee's venogram balloon against the vein's wall effectively reduced the acuteness of the angle of the side branch and this permitted the over the wire LV lead to be further advanced over the runthrough-NS floppy guidewire to reach a stable pacing position.
case_images: fcvm-09-892122-g006.jpg
case_images: PMC9280357_05_fcvm-09-892122-g006.jpg
case_images: F6
case_images: The CS venogram via Lee's venogram balloon catheter showed a very angulated and tortuous target vein (inferolateral side branch) (Figure 6A and Video 5). One runthrough-NS floppy guidewire (Terumo) was sent through Lee's venogram balloon catheter to the great cardiac vein for anchoring and then through Lee's venogram balloon catheter into the second runthrough-NS floppy guidewire (Terumo) to the target vein (Figure 6B and Video 5). Using this "double wire technique," tortuosities in the target branch are straightened, allowing uninhibited lead advancement (Figure 6C and Video 5). By keeping both wires in the side branch, a wire that is positioned against the wall of the vein can decrease the sharp angle, permitting the over the wire LV lead (Quartet 1458Q, St Jude Medical) to be finally delivered to the inferolateral branch over the other guidewire (Figure 6D and Video 5).