Achieving Permanent Left Ventricular Pacing—Options and Choice

Abstract

Cardiac resynchronization therapy (CRT) requires permanent left ventricular (LV) pacing. Coronary sinus (CS) lead placement is the first line clinical approach but can be difficult or impossible; may suffer from a high LV pacing threshold, phrenic nerve stimulation, and dislodgement; and produces epicardial LV pacing, which is less physiological and hemodynamically effective and potentially more proarrhythmic than endocardial LV pacing. CS leads can usually be extracted with direct traction but may require use of extraction sheaths. Half of CS side branches previously used for lead placement may be unusable for the same purpose after successful lead extraction, and 30% of CS lead reimplantation attempts may fail due to exhaustion of side branches. Surgical epicardial LV lead placement is the more invasive second line approach, produces epicardial LV pacing, and has a lead failure rate of approximately 15% in 5 years. Transseptal endocardial LV lead placement is the third line approach, can be difficult to achieve, but produces endocardial LV pacing. The major concern with transseptal endocardial LV leads is systemic thromboembolism, but the risk is unknown and oral anticoagulation is advised. Among the new CRT recipients in the United States and Western Europe between 2003 and 2007, 22,798 patients may require CS lead revisions, 9,119 patients may have no usable side branches for CS lead replacement, and 1,800 patients may require surgical epicardial LV lead revision in the next 5 years. The CRT community should actively explore and develop alternative approaches to LV pacing to meet this anticipated clinical demand.

Epicardial leads in adult cardiac resynchronization therapy recipients: A study on lead performance, durability, and safety

“…13 With the increasing number of CRT recipients, the number of patients in whom transvenous LV lead placement is impossible continues to rise. 14 Consequently there has been a growing interest in alternatives for transvenous lead placement, such as video-assisted thoracoscopic LV lead placement and transapical and transseptal endocardial lead implantation. [15][16][17] Moreover, there has been a renewed interest in epicardial LV leads, with the development of novel implantation techniques and new lead technologies.…”

Advanced Techniques for CRT Implantation

“…The most dangerous problem of the surgically implanted epicardial leads, usually used as a rescue technique, is the possibility of chronic increase of threshold, even the loss of permanent CRT. The different surgical epicardial lead implantation reports confirmed excellent long-term results on the basis of the 3 and 6-7 month follow up, but during the 1-5 year follow-up epicardial leads might have a significantly higher failure rate, than the CS leads (Lau, 2009). The benefit of this approach is the direct visual control of the latest contracting segment during the implantation, there is no limitation of the coronary venous anatomy for lead placement and the smaller incidence rate of lead dislodgment and phrenic nerve stimulation.…”

Long-term experience with coronary sinus side branch stenting to stabilize left ventricular electrode position

“…16 An important cause of suboptimal lead positioning, lead dislodgement, or extracardiac stimulation is the unstable electrode position in the target vein. 17 The original idea was that CS stenting may decrease the dislocation rate and improve the success rate of lead implantation into the recommended side branches by anchoring the LV lead in an anatomically unstable position. 9 CS stent implantation was first used in cases of postoperative lead dislocation.…”