scholarly journals A successful placement of the left ventricular lead for the cardiac resynchronization device using the orthodromic snare technique: clinical case

2021 ◽  
Vol 12 (3) ◽  
pp. 112-119
Author(s):  
Oleg L. Dubrovin ◽  
Pavel L. Shugaev

Background: The main aim of Cardiac Resynchronization Therapy (CRT) is a positive response of the patient, particularly, reduction of the symptoms and improvement of the heart contractility, that can be reached in 5070% of patients. The possibility of appropriate positioning the left ventricular (LV) lead is of great importance for the response to CRT. Certain instruments and technical approaches are used for the placement of the LV lead. Here, we describe the use of the orthodromic snare technique, which is quite rare in practice, but allows one to overcome some anatomical obstacles. Clinical case description: Patient A., suffering from the heart failure with a low ejection fraction and left bundle branch block, was admitted to the hospital for CRT implantation. Before the operation, all the necessary routine instrumental and laboratory diagnostics was performed. During the operation, venography of the cardiac veins revealed unsuitability of the lateral cardiac vein for the placement of the LV lead due to its very small diameter. The posterolateral vein was suitable for the LV lead implantation but still had some anatomical difficulties: an acute angle of inflow and local stenosis in the proximal segment. During the procedure, the following techniques were used without success: positioning the LV lead by a simple translational movement forward, a subselective catheter, introduction of several coronary guides in order to smooth out the acute angle of inflow. These circumstances warranted the use of the orthodromic snare technique for a successful LV lead placement. Conclusion: This clinical case illustrates the possibility of a safe and effective use of the orthodromic snare technique for LV lead implantation. Such anatomical difficulties as a small diameter, acute angle of inflow, local stenosis have also been illustrated and discussed.

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
F Anselme ◽  
F Ziglio ◽  
N Shan ◽  
LIB Heckman ◽  
M Kuiper ◽  
...  

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): H2020-FTI [Fast Track to Innovation] Pilot-2016 and MicroPort CRM Background Left ventricular (LV) lead positioning is an important contributor to cardiac resynchronization therapy (CRT) response. Multiple additional LV sites could be stimulated by passing a new ultra-thin (1.2 Fr, 0.4 mm) quadripolar microlead from one LV vein into another via venous collaterals. Purpose Study the acute and chronic stability and electrical pacing performance of a novel 1.2 Fr quadripolar microlead ("Axone 4LV"). Methods Seven healthy adult dogs underwent CRT defibrillator implantation, including a right ventricular lead and the microlead. The microlead was advanced into the coronary sinus network using a dedicated microguide catheter. The animals were followed up at 1, 15, 30 and 90 days post-implant to evaluate chronic stability and electrical pacing performance. Results Successful uncomplicated implantation was achieved in all cases. Despite the small diameter of the distal veins and collaterals, placement of the pacing electrodes in two different LV veins was feasible via available collateral passages. Lead position was stable in all cases and over the entire study period. Capture threshold and pacing impedance at 90 days post-implant were 1.7 ± 0.5 V with 1323 ± 245 Ω, respectively, at 0.5 ms pulse width. The mean pacing energy to get capture was 1.1 ± 0.5 µJ and less than 2 µJ in all cases (2 µJ ≈ 1.4 V @500 Ω, 0.5 ms). No phrenic nerve stimulation was observed during pacing. Conclusions The novel 1.2 Fr quadripolar microlead demonstrated adequate stability and good electrical performance allied to low energy consumption. This quadripolar microlead may extend pacing options while increasing device longevity in CRT. Changes in pacing parameters over time Post-implant Follow-up Pacing Threshold Pacing Impedance Pacing Energy 1 day 1.4 ± 0.7 V 1294 ± 270 Ω 0.8 ± 0.7 µJ 15 days 1.9 ± 0.9 V 1336 ± 274 Ω 1.8 ± 1.8 µJ 30 days 1.8 ± 0.7 V 1187 ± 303 Ω 1.5 ± 1.2 µJ 90 days 1.7 ± 0.5 V 1323 ± 245 Ω 1.1 ± 0.5 µJ


EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
T Zaremba ◽  
B Tayal ◽  
A M Thogersen ◽  
S Riahi ◽  
P Sogaard

Abstract Background One third of patients receiving cardiac resynchronization therapy (CRT) do not respond to the treatment, possibly due to suboptimal lead position and persistent dyssynchronous left ventricular (LV) contraction. Purpose To assess the influence of LV lead position on improvement of contractile asymmetry and its significance for LV reverse remodeling after CRT. Methods Patients with heart failure and left bundle branch block undergoing CRT implantation were studied retrospectively. Assessment of mechanical delay within the LV was assessed using a recently developed index of contractile asymmetry (ICA). ICA was calculated as standard deviation of differences in systolic strain rate in the opposing LV walls derived from curved anatomical M-mode plots. LV was divided into 12 equally sized 30-degree sectors. Spline interpolation was used to estimate ICA in six opposing sector pairs permitting quantification of regional contractile asymmetry in the entire LV. Position of LV lead tip was assessed by thoracic computed tomography (CT). Response to CRT was defined as a reduction of LV end-systolic volume (ESV) ≥15% after 6 months. Results Study population (n= 26) consisted of 65.4% males, 68 ± 10 years, ischemic etiology in 42.3%, LV ejection fraction 24.1 ± 5.8%, QRS duration 171 ± 22 ms. CRT response was present in 18 (69.2%) patients. Pre-implantation ICA in the LV sector containing LV lead was 0.75 ± 0.24 s-1 in responders vs. 0.46 ± 0.16 s-1 in non-responders (p = 0.003). Reduction of ICA in the LV sector with LV lead was directly correlated with reduction of LV ESV after CRT (r = 0.46, p = 0.02) (Figure 1). ICA reduction in the LV sector with LV lead was -0.24 ± 0.28 s-1 in responders and -0.05 ± 0.16 s-1 in non-responders (p = 0.03). Meanwhile, reduction of ICA in the LV sectors located 60 degrees clockwise and 60 degrees counterclockwise away from the LV sector with LV lead (remote LV sectors) did not differ significantly between responders and non-responders: -0.12 ± 0.15 s-1 vs. -0.06 ± 0.1 s-1 (p = 0.28). Likewise, no significant correlation between reduction of ICA in remote LV sectors and LV ESV reduction was observed (p = 0.11). Conclusion Pre-implantation contractile asymmetry in the LV lead target area is associated with a positive response to CRT. Simultaneously, the degree of LV reverse remodeling after CRT seems to correlate with the magnitude of improvement of contractile asymmetry specifically in the region of LV lead location. Abstract Figure 1


Author(s):  
Thijs Stoker ◽  
Theo J. Klinkenberg ◽  
Alexander H. Maass ◽  
Massimo A. Mariani

We describe two cases in which a biventricular implantable cardioverter defibrillator for cardiac resynchronization therapy had to be placed on the right side due to unsuitability of the left subclavian vein. Endocardial implantation of a left ventricular lead through the coronary sinus was previously attempted but was unsuccessful. Implantation of the epicardial left ventricular pacing lead was performed through video-assisted thoracic surgery on the left side. The connector end of the left ventricular pacing lead was tunnelized through the anterior mediastinum into the right pleural space. The right-sided pocket was then opened. A tunnel was created from the pocket to the thoracic wall, and the pleural space was entered over the second rib. The lead was retrieved from the right pleural space and connected with the Cardiac resynchronization therapy-device (CRT-D). Both procedures and postoperative periods were uneventful. Intrathoracic left-to-right tunneling of an epicardial left ventricular lead by video-assisted thoracic surgery is feasible and safe. It provides an alternative to subcutaneous tunneling.


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