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a
c
b
d
Fig. 24.39 Double cannulation approach to coronary venous lead
placement in the setting of a prominent Thebesian valve. Panel ( a ): 2-D
axial view ( a ) demonstrating a well-formed and prominent Thebesian
valve ( black arrow ) covering the coronary sinus ostium. Serial intrapro-
cedure fl uoroscopy images showing the sequential stages of coronary
sinus cannulation and coronary venous left ventricular lead placement.
Panel ( b ): placement of 7 French steerable decapolar coronary sinus
catheter ( white arrow ) from a right femoral vein into the coronary sinus
ostium (right anterior oblique [RAO] view). Panels ( c and d ): coaxial
alignment of both 7-French multipurpose sheath with the inner sheath
engaged in the coronary sinus ostium ( black arrow ) with a torque wire
extending into the great cardiac vein ( double black arrow ) and 7-French
steerable decapolar coronary sinus catheter from the right femoral vein
( white arrow ) (RAO view). Panel ( d ): 7-French multipurpose outer and
inner sheath have been pulled back to the mid right atrium ( black
arrow ). The torque wire from left subclavian approach ( double black
arrow ) and 7-French steerable decapolar coronary sinus catheter from
the right femoral vein ( white arrow ) have been advanced further into
the great cardiac vein (RAO view) (Reprinted from Cao et al. [
196 ] with
permission from John Wiley and Sons)
24 CCTA Cardiac Electrophysiology Applications: Substrate Identifi cation, Virtual Procedural Planning, and Procedural Facilitation
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sinus ostium in relation to the fl oor of the right atrium has
been identifi ed as a factor leading to challenging CRT coronary venous lead placement with a high coronary sinus
ostium [ 197 ]. In cases where the coronary venous anatomy is
not amenable to a venous approach to left ventricular lead
placement, CCTA can facilitate planning of approach to
epicardial lead placement (Fig. 24.40 ). Postprocedurally,
CCTA is useful for 3-D assessment of pacemaker and ICD
lead placement. With CRT, postprocedure CT was more
accurate than fl uoroscopy and chest x-ray for documentation
of exact lead position [ 198 , 199 ]. CCTA can detect lead per-
foration as evidenced by a lead tip visualized beyond the epi-
cardium and can also demonstrate the presence of pericardial
effusion [ 200 – 203 ].
Non-response is an issue in approximately one third of
patients undergoing CRT. The correlation between CCTA
visualized sites of coronary venous branch veins and echo
derived area of latest mechanical activation has been associated with acute response to CRT, with lack of response
associated with disparity in location between these sites
[ 204 ]. The CMR literature has shown that the amount and
location of myocardial infarct scar is important to CRT
response. The percent total scar derived from delayed gadolinium enhancement imaging has predicted response to
ab
cd
Fig. 24.40 2-D ( a ) and 3-D ( b – d ) views demonstrating anterior rota-
tion of the left ventricle and relation to skeletal structures useful to planning a minimally invasive approach to epicardial left ventricular lead
placement in a patient with coronary venous anatomy not amenable to
a percutaneous approach to cardiac resynchronization therapy
J.S. Shinbane et al.
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CRT, with greater response in patients with less than 15 %
percent total scar and poor response in patients with posterolateral scar [ 205 – 207 ]. CCTA delayed contrast enhance-
ment imaging for assessment of non-response requires
study. Comprehensive analysis of factors important to
response to CRT including coronary venous anatomy, 3-D
global and regional ventricular function, and delayed
enhancement require further assessment for CRT planning
and facilitation to maximize response.
Conclusions
CCTA provides extensive imaging data important to the
diagnosis and treatment of electrophysiologically-relevant
cardiovascular disease. Advanced cardiac imaging has furthered the fi eld of cardiac electrophysiology and will continue to have an impact through application to a greater
spectrum of arrhythmogenic substrates as well as ablation
and device procedures.
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