How to manage coronary sinus venous perforation during left ventricular lead implantation: a case report.

Background: Coronary sinus venous branch stenosis is an uncommon entity. Balloon dilatation of venous tributary may not always be safe. We report a case of venous perforation following balloon dilatation, which was managed by glue occlusion and completion of cardiac resynchronization therapy (CRT) implantation.

Case summary: A 50-year-old man was diagnosed with non-ischaemic cardiomyopathy with New York Heart Association (NYHA) Class III dyspnoea despite optimal medical therapy. The electrocardiogram showed a left bundle branch block with a QRS duration of 168 ms, and 2D echocardiography revealed dilated cardiomyopathy with a left ventricular ejection fraction of 20%. The patient was taken for CRT implantation; however, there was severe stenosis in the posterolateral vein noted during left ventricular (LV) lead implantation, hindering LV lead advancement. Following balloon dilatation, there was perforation of the vein with hypotension. The perforation was sealed with glue injection (n-butyl-2-cyanoacrylate), and LV lead placement was performed. At the 4-year follow-up, the patient is in NYHA Class I and the ejection fraction improved to 60%, with an excellent LV threshold and good synchronization.

Discussion: Glue (n-butyl-2-cyanoacrylate) occlusion can manage coronary sinus perforation with suitable long-term LV lead parameters.