Intercommissural lead placement into a right ventricular coronary sinus-utility of intracardiac echo guidance

Patients with congenital heart disease and prosthetic valves frequently present management dilemmas related to cardiac pacing and lead placement. Permanent pacing of the right ventricle across a bioprosthetic tricuspid valve presents discreet issues related to its potential for traumatic injury and subsequent prosthetic valve dysfunction. Coronary sinus (CS) lead placement is being used more frequently to avoid valvular dysfunction. We report an unusual case in which the CS ostium was located ventricular to the tricuspid prosthesis. Intracardiac echocardiography was used to position a CS lead between the commissures of the tricuspid prosthesis resulting in trivial regurgitation acutely and at 1-year follow-up. (PACE 2011; 34:e30-e32)