[1] Thanks very much Burce, unfortunately I think in the course as Bruce said each case is a case study. For those of us who have been doing this since the first clinical trial we have struggled through substantial pains in the os and the good news is it’s getting a little bit easier, but still some difficulties. Let’s just step through some anatomy and I would be interested in your comments and questions because everybody learns from each case. [2] Find the CS Os and I hope that Seth shows up because I learned some of this from him. How do you find the CS Os? It used to be quite a challenge; it seems to be getting easier. I’d like to think that we are getting better; in fact, I think the technology has gotten better. We’ve, also, learned about what not to do, so just a few tips/tricks that I’ve learned from other folks and some discovered myself. First I generally recommend the use of a sheath with a lumen catheter inside to find the Os and I’ll show you a video about that. The second trick is to look for the fat pad in the AV ring as a guide to reposition, at least on the REO picture of the location of the CS. If you puff dye at the fat pad junction with acute margin you can see a whorl of dye at the CS Os or in the pouchy station pouch and then you move the sheath or catheter in the plane of the fat pad away from the acute margin you can generally get in the CS, [3] so here’s a video that I hope plays here. Let’s just go back one here. Anyway, so here’s a catheter coming down from above the right atrium. This is a puff of dye injected across the tricuspid valve, we swing back, and do you see the dye hang-up in the subeustachian recess there. If you were too far posterior, you’re on the other side of the eustachian ridge and dye gets injected in the ventricle, so you then rotate back towards the location where the dye hangs up, move forward and generally you are at the os. I’m trying to get the slide to advance forward here, but it’s not doing it. Is there a way to advance the slide? [4] There we go. Let’s go, alright here we go. This is a postmortem specimen, it’s showing the pouch against not the same view, this is the right atrium here, left atrium IVC, here’s the pouch where the dye hangs up when you inject here and it hangs up because you’ve got flow coming from above and from below into this area and you’ve got flow coming out of the coronary sinus this way, so you end up with a vortex here. That’s why it hangs up and it, also, hangs up because of the anatomy. Here is the thebesian valve that protects the origin of the coronary sinus; so again, this is just one trick for locating the os with contrast. [5] Now, another trick that I use is to look for fat, which you can see on if you have reasonably high-quality fluoro, I hope that the images I captured show it, but fat shows up substantially more lucent than muscle and this is the right atrium here. This is the right ventricle, here is a substantial amount of fat in the AV ring and the difference between fat here and fat here is if there is much less cardiac muscle in this plane of the AV ring. Let me [6] just show you this on fluoro. This is an REO fluoro and you can see this was somewhat late in the game. There is a little bit of staining down here, so the RV lead here or A-lead we’re trying to get in the CS. Now, if you look in this plane right here, you’ll see it’s slightly more lucent than the rest of the heart on either side. Here is the acute margin, here is some contrast that hung up in the tricuspid valve apparatus and see if this plays here. You can see this kind of lucent shadow and I always tell the fellows it’s like looking up at the sky and seeing the Milky Way, you kind of have to imagine it just a little bit, but it’s there. You’ll see that the CS is just on the atrial side of this. Now for the very astute and omnicompetent of the audience this is a stent. Now the stent could be in the right coronary, it could be in the circumflex and if I can see the next slide. [7] Click outside this. Here is…we can go back one, okay, so here is the lead in and you can see this lucent area right along here, and again, that is the fat pad and the AV ring and the os is generally in this plane where it’s positioned relative as you get to margin depends on the size of the atrium, clearly in a patient with a very markedly enlarge atrium, the os is going to be higher up in this plane. [8] Now here’s an LAO, the lead is in and here’s our stent over here. The stent is in the circumflex system. Again, in the REO it’s difficult to tell whether the stent was in the right or the left system, but again, just a trick for finding the os on standard fluoro. [9] Now we’re doing some work with intracardiac ECHO at the time of CRT. We’re in the beginning phases of this study. One of our fellows, Brian Powell is working on this. Fortuitously, it can help you find the os in a difficult case and [10] this is again, Acuson Phased Array ECHO at the time of CRT implant and this is a lumen filled catheter injecting saline at a fairly generously-sized CS os and it was quite a large heart and actually helped us get into the os when fluoroscopy and contrast injection was difficult. Again, it’s not something that is done in a standard way, but we may see more use of various real-time imaging studies to guide placement of leads that as we make it to the point where imaging physicians will tell us implanters where to go, it will make for some interesting conversations in the procedural suite. [11] Now what about the really big heart? This is a patient that I took care of. His left ventricular end diastolic dimension (LVEDD) was 93 mm. His end systolic dimension was 84, either one of those is scary. EF was 18 and we had a heck of time find the os. Now folks like this often don’t tolerate a dye load very well and we’ve all learned that we are now taking care of the sickest of the sick. Tricks that you probably know include doing a coronary arteriogram and looking for the Levo phase, the CS affluent or puffing lots of contrast from above, but then you subject the patient to a dye load. Something that was published by David Ross from Australia a number of years ago is using a sheath from below to get into the os and the one I use is a Daig SL3. [12] This just shows, I think it’s an AP or a semi-LAL. This is an SL3 sheath from below and we put a catheter just inside the CS here, brought us EPT guiding catheter up this way and found the os, so we stabilized the position from below and we identified it from the position below and came in from above. [13] This is a different patient. We were doing it for a different reason. Again, this shows that with that technique you can actually get an EP catheter all the way around the great cardiac vein. This actually helps in other situations, as well outside of CRT. [14] Now there is a few new technologies out there developed to help folks find the CS and this is one that was developed by a Stanford med student, Chris Eversull. I had a chance to meet him and see his presentation he was kind enough to share it with me. This is an approved device with a very small company. It’s essentially a catheter with a compliant balloon at the end that chases the blood out of the way, an imaging element, and then a guidewire lumen through which you can pass at least a guidewire, if not a lead. [15] These are some of the images that you shared with me. This is coming down towards the CS from above. You’re looking at the interatrial septum; you’ll see the CS os come into view here. There is the CS os. At that point, you can pass the guidewire through the guiding sheath. Again, the exact stent, which is going to be necessary, unclear, but an interesting technology may become useful when we go for more difficult cases than we are already doing. [16] Another one, and this is CardioOptics, they have a booth here. Ty Davenport was kind enough to send me this information. Now this is a device for direct visualization of intracardiac structures through the blood pool and it consists of a catheter that has an infrared illuminating ring and then an imaging capture lens, so this is actually a light in a camera in the heart. [17] This is just a represented image here, so this is the coronary sinus here. This is the thebesian valve and you can see it at real-time the valve opening and closing which explains why sometimes you probe and you probe and you probe and eventually get in as long as you time it relative to the closure of that valve. [18] So, let’s say we got into the coronary sinus, now what do you do? The optimal site is generally believed to be lateral or posterolateral. Much of these data were based on original observations from Aurricchio PATH-CHF study, very detailed hemodynamic studies with epicardial placement of pacing sites. The initial observations have been supported by retrospective studies of responders and non-responders and again, I think we’re probably at some point going to have imaging physicians tell us where to put leads and I think we have a mouse disconnection here. Great, now we’re back. [19] This just shows Auricchio, so the interior interventricular vein, great cardiac vein, rotates the heart here on the lateral wall. Posteriolateral vein, you all know this anatomy and again, the left poster vein and an MCV here. Now what Auricchio and his colleague showed that if you paced the heart at different sites you get various changes in pulse pressure and TPDT. At the apex, you see a modest increase in these two perimeters, antral, apical, again modest increase, posterior apical, and the best sites in general according to their data, were in the middle posteriolateral LV and again, this is generally the areas we target. We can retrospective studies from Cleveland Clinic and elsewhere have shown that this does appear to be the best target. Now we may find that real-time, for instances, tissue Doppler will tell us, [20] otherwise; in specific patients. So let’s say we got into the CS, we got past all those obstructions, but we don’t see any branches [21] and this is not uncommon and here’s a representative video here, so CS well-cannulated balloon venogram – nothing, always disconcerting. [22] In lateral, CS well a pacified, balloon is deflated, no branches. So what do we do here? [23] Well, in fact, there have to be branches, otherwise; the heart wouldn’t work real well. This is the same patient where we got a lead in a posterior vein quite nicely. [24] and again, in an LAL we got it out to a nice posteriolateral position, so why is that? [25] Well, the CS affluent can be traveling at quite a high volume and speed and simply by Venturi effect not allow contrast to pass into these veins. In addition, these veins seen here are often protected by little, almost like sinuses of Valsalva, their kind of recessed and so they are protected from the dye that you’re trying to inject into them, so it’s not uncommon to not see them. If you put a small sub-selecting catheter in you can engage these veins and it’ll past by them very nicely. So if you don’t see branches, use a small sub-selecting catheter, Divan has one, Medtronic has one, Daig makes them, as well. [26] Again, the other key is to make sure you deflate your balloon at the time of your injection so you fill back to the os. [27] Now CS valves, I wasn’t sure that these things existed until I went back and read my anatomy text and then ran into them headlong in cases. If you see a valve, the trick I found is if you use a bigger, rather than a smaller guidewire or a sub-selection catheter to go past it, but be very careful with balloon angiography catheters, because the tips are not uncommonly quite sharp and you can go subintimal very easily. [28] These are data from my colleague Sam Asirvatham. This is just shows the thebesian valve at the orifice of Vieussens valve more distally. It can cover a substantial portion of the orifice. [29] Here is a valve here, a couple of valves actually you can see a lucency right about here. Very sluggish flow in this very sick patient and it was somewhat difficulty to negotiate this first valve. [30] Now this is a quote from Mick Jagger, “You Can’t Always Get What You Want,” you hope you get what you need and we’ve all been in a situation where nothing we find out in the more lateral sites is helpful. [31] This is the middle cardiac vein bailout option against the data from Sam Asirvatham in a substantial number of patients about two hundred and nineteen dissections he did. The majority of the time the middle cardiac vein comes off like this, like there’s a separate ostium in a handful of patients, so it may come off in an entirely separate ostium. So be aware of the vagaries of anatomy. [32] Again, this is a cartoon showing how to get MCVs, so you cannulate the CS. This shows using a standard EP catheter. You go counter clockwise to get in the CS, but if you want to go into the MCV, you pull back; rotate clockwise to come interior, drop in the middle cardiac vein. At this point, you can pull back; deflect your chip to get a little tension. It straightens out the angulation and it’s probably best to use a softer, straighter sheath at this point and see if you can actually get this sheath and sub-selected into the MCV. Then you pull your catheter out and your home free. Now Seth Worley will tell you how to get from the middle cardiac vein to anywhere else in the heart you want to. I won’t pretend to do that. I think that is the last one if you can advance it for me over there. There are a few tricks of anatomy, things that might get you through the day and if we have time now or later we can answer some questions. Thanks very much. [33]

Robert Rea Ballroom E Trying to Avoid a Pain in the Os: Tips and Tricks in Navigating the Coronary Sinus How to Successfully Implant CRT: From Lead Placement to Programming