Alternative Techniques for Left Ventricular Pacing in Cardiac Resynchronization Therapy

Abstract

Cardiac resynchronization therapy (CRT) is an important treatment modality for a well-defined subgroup of heart failure patients. Coronary sinus (CS) lead placement is the first-line clinical approach but the insertion is unsuccessful in about 5-10% of the patients. In recent years, the number of CRT recipients and the considerable need for left ventricular (LV) lead revisions increased enormously. Numerous techniques and technologies have been specifically developed to provide alternatives for the CS LV pacing. Currently, the surgical access is most frequently used as a second choice by either minithoracotomy or especially the video-assisted thoracoscopy. The transseptal or transapical endocardial LV lead implantations are being developed but there are no longer follow-up data in larger patient cohorts. These new techniques should be reserved for patients failing conventional or surgical CRT implants. In the future, randomized studies are needed to asses the potential benefits of some alternative LV pacing techniques and other new technologies for LV lead placement are expected.

Epicardial left ventricular lead implantation in cardiac resynchronization therapy patients via a video‐assisted thoracoscopic technique: Long‐term outcome

“…There are several open‐chest techniques to implanting the LV pacing lead: median sternotomy, fully left thoracotomy, mini‐thoracotomy, video‐assisted thoracoscopy (VAT), and robotically assisted surgery . These approaches offer the advantages of direct visual control, with the possibility of choosing the lead‐tip position, less fluoroscopy use and the avoidance of intravenous contrast material, whereas the disadvantages are the need for general anesthesia, and the presence of epicardial fat and adhesions.…”

Leadless Cardiac Pacemakers: Pacing Paradigm Change

“…On the other hand, there may be significant benefits to leadless LV endocardial pacing. LV endocardial pacing is more physiological (endocardial-to-epicardial transmural activation sequence), may enhance LV diastolic and systolic performance, has the potential to be less proarrhythmic (reduced dispersion of ventricular repolarization), and likely requires lower pacing energy outputs, as compared to optimally placed coronary sinus leads [19,20]. Furthermore, LV endocardial pacing may offer a larger choice of optimal stimulation sites, since it is not limited by the availability of coronary sinus branches which can accommodate a transvenous lead, and there appears to be little risk of phrenic nerve stimulation.…”

Trans-Fontan baffle placement of an endocardial systemic ventricular pacing lead

“…Although once thought to be too risky given the possibility of thromboembolic complications, 7 alternative pacing strategies are being sought for heart failure patients who do not respond to more standard cardiac resynchronization strategies. Studies have described the technical feasibility of placing transvenous leads via an atrial transseptal puncture, 8 as well as a relatively acceptable thromboembolic risk: a study by Rademakers et al 9 noted a thromboembolic rate of 6.1 events per 100 patient-years, with all of the affected patients having subtherapeutic anticoagulation at the time of their event.…”