scholarly journals Endocardial pacing is not haemodynamically superior to trans-coronary sinus epicardial pacing in cardiac resynchronization therapy: the Endo-Epi CRT study

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
O Okafor ◽  
A Zegard ◽  
B Stegemann ◽  
S Arif ◽  
J De Bono ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Coronary Sinus ◽  
Intrinsic Rate ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Funding Sources ◽  
Pressure Wire ◽  
Epicardial Pacing ◽  
Endocardial Pacing

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Medtronic Background Cardiac resynchronization therapy (CRT) conventionally involves trans-coronary sinus, epicardial left ventricular (LV) pacing. Some studies have suggested that endocardial LV pacing may be superior to epicardial LV pacing. Objectives To compare the acute haemodynamic effects of CRT when delivered from endocardial (Endo-CRT) and epicardial LV stimulation sites (Epi-CRT). Methods and results Sixteen CRT recipients (aged 70.4 ± 10.1 years [mean ± SD], 62.5% male, QRS: 156.5 ± 16.1 ms, LBBB in 13 [81.3%]) in sinus rhythm underwent intra-procedural measurements of the rate of rise of LV pressure (dP/dtmax) during Endo- and Epi-CRT (RADI pressure wire). Epi-CRT was delivered in basal, mid and apical positions. The Endo-CRT pacing site was chosen using iterative, biplane fluoroscopic views, to target the same position as the Epi-CRT site on the endocardium (see Figure A). Compared to AAI pacing (10 beats per minute above intrinsic rate), both Endo-CRT and Epi-CRT led to an increase in LV dP/dtmax (6.52 ± 8.90% and 6.15 ± 7.97% respectively, both p < 0.001). There were no significant differences in the change in LV dP/dtmax (ΔLV dP/dtmax) between Endo-CRT and Epi-CRT at basal (p = 0.54), mid (p = 0.78) or apical LV stimulation sites (p = 0.12) [Figure B]. Conclusions Endo-CRT is not haemodynamically superior to Epi-CRT. Abstract Figure.

scholarly journals Cardiac resynchronization therapy in coronary sinus atresia delivered using leadless endocardial pacing

2016 ◽  
Vol 2 (5) ◽  
pp. 432-435 ◽  
Author(s):  
Dewi E. Thomas ◽  
Nicholas M. Child ◽  
W. Andrew Owens ◽  
Nicholas J. Linker ◽  
Simon A. James ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Coronary Sinus ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Endocardial Pacing

scholarly journals Cardiac resynchronization therapy system implantation complications

2021 ◽  
Vol 27 (3) ◽  
pp. 7-15
Author(s):  
Svetoslav Iovev ◽  
Peyo Zhivkov ◽  
Mariana Konteva
Keyword(s):  
Heart Failure ◽  
Congestive Heart Failure ◽  
Cardiac Resynchronization Therapy ◽  
Coronary Sinus ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Successful Therapy ◽  
Resynchronization Therapy ◽  
Established Method

Cardiac resynchronization therapy (CRT) using coronary sinus (CS) leads is an established method for the therapy of congestive heart failure (CHF) in the case of asynchronous ventricular contractions. Successful therapy depends on the placement of left ventricular leads usually via the coronary sinus (CS), a technically more challenging procedure than regular pacemaker implantations. Without specifi c precautions CRT implantation can be the gateway to a time-consuming nightmare. Therefore, CS lead implantation methods, with a focus on complications, were reviewed according to the literature and our own experience with approximately 4500 procedures from 2002-2021.

scholarly journals Minithoracotomy as the primary alternative for left ventricular lead implantation during cardiac resynchronization therapy: Can the cardiac surgeon reduce the number of nonresponders

2017 ◽  
Vol 145 (11-12) ◽  
pp. 576-579
Author(s):  
Dragutin Savic ◽  
Svetozar Putnik ◽  
Milos Matkovic
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Coronary Sinus ◽  
Lateral Wall ◽  
Left Ventricular ◽  
Venous System ◽  
Cardiac Resynchronization ◽  
Left Ventricular Ejection ◽  
Resynchronization Therapy ◽  
Ventricular Ejection Fraction ◽  
Ventricular Lead

Introduction/Objective. Numerous anomalies of the cardiac venous system prevent the optimal endovascular implantation of the left ventricular (LV) lead in more than 15% of patients with indication for cardiac resynchronization therapy (CRT). The endovenous approach in these patients can be one of the potential reasons for the large number of nonresponders reported in the literature. The purpose of this study was to analyze the results of an alternative myoepicardial approach to the stimulation of the left ventricle in CRT. Methods. From June 2014 to December 2015 at the Department of Cardiac Surgery of the Clinical Centre of Serbia, 15 myoepicardial LV leads for CRT were implanted. Coronary sinus venography revealed thrombosis of the coronary sinus in nine patients, and unfavorable anatomy of the coronary venous system in six patients. In all patients, limited left thoracotomy was used as an approach to the lateral wall of the heart. Results. There were no major surgical complications and no lethal hospital outcomes. In a six-month follow-up period we registered a significant increase in the length of the six-minute walk test (for an average of 57.9 m), reduction of the QRS complex width (to 26.25 ms), increase in left ventricular ejection fraction (12.2%), and reduction of mitral regurgitation for 1+. Based on all the parameters, it was concluded that all patients responded favorably to the applied CRT. Conclusion. Closer cooperation between cardiologists and cardiac surgeons in identifying patients who would benefit the most from a myoepicardial approach for LV stimulation is necessary in order to attempt to reduce the nonresponder rate.

P544Evaluation of three-dimensional trajectory of pacing cathode pole in coronary sinus to predict long-term response to cardiac resynchronization therapy

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
C Tomasi ◽  
S Severi ◽  
F Zanon ◽  
G Molon ◽  
A Corzani ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Coronary Sinus ◽  
Predictive Value ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Reverse Remodeling ◽  
X Rays ◽  
Resynchronization Therapy ◽  
Volumetric Response

Abstract Background An automated method for 3D reconstruction of coronary sinus (CS) lead’s pacing cathode trajectory (3DTJ) was proposed  to acutely predict long term left ventricular (LV) mechanic response to  cardiac resynchronization therapy (CRT). Preliminary data showed that 3DTJ at biventricular pacing (BIV) start changed  in CRT responders (R) to be,  becoming less eccentric and more multi-directional, as described by the ratio between its two major axes (S1/S2). Purpose The TRAJECTORIES study (Trajectory Changes Of Coronary Sinus Lead Tip And Cardiac Resynchronization Therapy Outcome, NCT02340546) is an observational study by seven Italian centers about  the prediction of CRT-induced LV reverse remodeling by means of the acute 3DTJ changes at CRT implant. Methods In CRT implants with standard indications, stable CHF and regular ventricular rhythm,  a fluoroscopic sequence in two standard X-rays views of a few seconds was acquired immediately before (T-1) and after the start of BIV (T0). 3DTJ  of CS lead cathode pole throughout the cardiac cycle at T-1 and T0 were reconstructed and analyzed. Changes of the ratio between its two major axes (S1/S2) between T-1 and T0 (ΔS1/S2), were compared with the volumetric response at six-month f.u: the percent negative variation of S1/S2 (ΔS1/S2 < 0), marking a more multi-directional shape of 3DTJ, was assumed to predict the response to CRT. Volumetric response was adjudicated by a core-lab using a cut-off reduction ≥ 15% in echocardiographic LV end-systolic volume at f.u..  Results   Out of 119 patients enrolled in 42 months, 74 pts ended f.u. (55 m; age 69 ± 10) and 30 dropped–out. Patients baseline features were: ischemic heart disease (IHD) 34 /74 pts; sinus rhythm 64/74 pts; upgrade from PM/ICD 13/74 pts; QRS morphology with LBBB 57/74, intraventricular aspecific delay 6 and  RV pace 11 pts;  LV ejection fraction (EF) 30 ± 9%; QRS duration 162 ± 25 ms. At f.u., volumetric R were 45/74 (60%). Concordance between ΔS1/S2 (as either ΔS1/S2 < 0 or ΔS1/S2 > 0) and volumetric response was 77% overall (57/74), 82% in R (37/45), 69% in non-R (20/29). Non-concordant patients were mostly non-R: 52% vs  35% of non-R in concordant group, but no other differences were found. The proposed 3DTJ metric showed sensitivity = 72%, specificity =80%;  positive predictive value = 69%, negative predictive value = 82%. Conclusions Metrics of 3DTJ can be useful to acutely predict CS pacing site-specific response to CRT in long-term, above all in R. 3DTJ assessment might highlight aspects of  CRT effects  on LV mechanics.

864A modified snare technique improves left ventricular lead implant success and response rate to cardiac resynchronization therapy

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
A Nunes Ferreira ◽  
P S Antonio ◽  
I Aguiar-Ricardo ◽  
T Rodrigues ◽  
J Rigueira ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Coronary Sinus ◽  
Surgical Intervention ◽  
Response Rate ◽  
Standard Technique ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Lead Placement ◽  
Implant Technique

Abstract Introduction Left ventricular (LV) lead placement is often the most challenging aspect of cardiac resynchronization therapy (CRT) device implantation, with a failure rate up to 10% due to complex coronary anatomies. Purpose To evaluate the efficacy of a modified snare technique in the LV lead implantation in cases of standard technique failure and to evaluate its impact in the response rate to CRT. Methods A prospective study was conducted of patients indicated for a CRT implant. When LV lead delivery to the target vessel failed using standard techniques, a modified snare technique was implemented, using a secondary coronary sinus delivery sheath introduced through the same venous puncture.  Patients were evaluated every 6 months. Efficacy was quantified by long-term surgical intervention rates. Patients were evaluated with transthoracic echocardiography before CRT implant and between 6-12 months post-implant. Patients with ejection fraction (EF) elevation ≥ 10% or LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Time to surgical revision and mortality were evaluated by the Cox regression and Kaplan-Meier methods. Results From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). The standard LV implant technique failed in 94 cases (16.6%), of which the modified snare technique was successful in 92 (97.9%) with LV lead implant in a lateral vein in 94.7% of cases. Baseline clinical characteristics were similar between patients who implanted LV lead with snare vs standard technique (p = NS). The 4-year surgical intervention rate was lower with the modified snare implant technique than with the standard technique (3.2% vs. 10.2%, HR 0.26, 95% CI 0.08-0.84, p < 0.05), with a relative risk reduction of 74% and a number needed to treat to prevent one surgical intervention of 14. The intervention rate was also lower regarding LV lead implant failure or dislodgement rates (0% vs. 5.3%, p < 0.05). Major complications were similar between groups. In addition, the response rate to CRT was higher in the modified snare technique than in the standard approach (71.1% vs 55.0%, p < 0.05). In patients who implanted the LV lead with the snare technique, EF increased from 28.1 ± 8.2% to 36.1 ± 11.1% (p < 0.05) and LV ESV decreased from 127.8 ± 64.0mL to 99.8 ± 61.1mL (p = 0.01). The super-response rate was similar between groups (33.3% vs 27.8%, p = NS). Conclusion For challenging coronary sinus anatomies that preclude LV lead placement by standard methods, this modified snare alternative was effective, with significantly lower surgical intervention rates and a higher response rate to resynchronization therapy. This higher than expected response rate with the snare technique, evaluated by remodeling criteria, may be explained by the implant of LV lead in the desired target lateral vein. Abstract Figure.

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