Biventricular ICD implant using endocardial LV lead placement from the left subclavian vein approach and transseptal puncture via the transfemoral route

Nuta, Bogdan; Lines, Ian; MacIntyre, Inga; Haywood, Guy A.

doi:10.1093/europace/eum176

Cited by 28 publications

(28 citation statements)

References 3 publications

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“…17 The atrial transseptal approach to LV endocardial pacing was initially described by Jaïs et al 10 Modifications of the technique have been developed for the past decade, but it remains complex, with a combined inferior and superior approach used to puncture the atrial septum and deliver a lead from the subclavian vein. [9][10][11][12][13] Balloon dilatation of the septum and the use of snares to feed guidewires or pacing leads across into the left atrium is a common feature. [9][10][11][12][13] In the present study, all patients had a successful procedure using only the upper chest venous access site, reducing complexity.…”

Section: Discussionmentioning

confidence: 99%

“…8 Several variations of a percutaneous atrial transseptal route for LV endocardial pacing have also been described, but all are complex, expose a significant length of the lead to the systemic circulation, and may potentially interfere with mitral valve function. [9][10][11][12][13] Access to the LV endocardium through the interventricular septum may offer a simpler and more direct route for CRT. We have previously described LV endocardial pacing via the transinterventricular septal route in 1 patient.…”

Section: Clinical Perspective On P 22mentioning

confidence: 99%

See 1 more Smart Citation

Development of a Technique for Left Ventricular Endocardial Pacing via Puncture of the Interventricular Septum

Betts

Gamble

Khiani

et al. 2014

Circ: Arrhythmia and Electrophysiology

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Background-Left ventricular (LV) pacing through the coronary sinus is the standard approach for cardiac resynchronization therapy. When this route is unavailable, the alternatives have major limitations. LV endocardial pacing through the interventriuclar septum may offer a simpler solution. We describe an initial case series to demonstrate technical feasibility and to describe our refinement of the puncture technique. Methods and Results-Ten patients with previous failed coronary sinus lead implant or with nonresponse to cardiac resynchronization therapy and a suboptimal LV lead position were selected. All patients were anticoagulated. Left ventriculography and coronary angiography were performed to identify LV borders and septal vessels. Subclavian vein access was used for a superior approach ventricular transseptal puncture under fluoroscopic guidance, using a steerable sheath and a standard transseptal needle, radiofrequency needle, or radiofrequency energy delivered through a guidewire. An active-fixation pacing lead was successfully delivered to the endocardial wall of the lateral LV in all patients (9 men; age, 62±10 years). LV lead implant procedure time shortened with experience. The use of radiofrequency energy delivered through a guidewire was the most effective technique. Mean threshold and R wave at implant were 0.8±0.3 V and 10.8±3.9 mV. At follow-up (mean, 8.7 months; minimum, 0; and maximum 19), thresholds were stable, and there were no thromboembolic events. Of 9 patients, 8 were classed as clinical responders (1 had inadequate follow-up to assess response). Conclusions-LV endocardial pacing through a ventricular septal puncture is a feasible approach for cardiac resynchronization therapy. (Circ Arrhythm Electrophysiol. 2014;7:17-22.)Key Words: cardiac resynchronization therapy ◼ endocardium ◼ heart ventricles ◼ septal Received September 11, 2013; accepted December 16, 2013. From the Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (T.R.B., J.H.P.G., R.K., Y.B., K.R.); and Department of Cardiology, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, United Kingdom (R.K. Figure 1). Once a LV pressure trace was seen, a hand injection of contrast media was used to confirm that the needle was in the LV cavity. The dilator and sheath were then advanced 10 to 20 mm into the chamber over the needle. The needle was withdrawn and a 0.032-inch stiff 260-cm J guidewire was advanced through the sheath and dilator and curled in the LV cavity. The sheath and dilator were then advanced through the septum until the sheath tip was 1 to 2 cm inside the LV. The sheath and dilator were withdrawn and exchanged over the stiff guidewire for a slit-able, deflectable lead delivery catheter and dilator (Medtronic Attain or Select Secure; Medtronic, Minneapolis, MN). 2. Radiofrequency needle (cases 2 and 3): the procedure was performed using a stiff 98-cm radiofrequency transseptal needle (NRG; Bayliss Medical, Montreal, Canada). When opposed against the s...

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Section: Discussionmentioning

confidence: 99%

Section: Clinical Perspective On P 22mentioning

confidence: 99%

Development of a Technique for Left Ventricular Endocardial Pacing via Puncture of the Interventricular Septum

Betts

Gamble

Khiani

et al. 2014

Circ: Arrhythmia and Electrophysiology

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“…Another group has described a method using direct TS puncture from the left axillary vein [18]. In 2007 Van Gelder et al and Nuta et al described successful endocardial LV lead placement from the subclavian vein into the LV cavity via the interatrial septum, following transseptal puncture through the femoral vein to allow entry of the LV lead from above [15,16]. In our patients, we used the latter approach.…”

Section: Discussionmentioning

confidence: 99%

“…In patients with advanced heart failure, this approach may be linked with a high morbidity and mortality. Endocardial LV lead placement through an atrial transseptal approach has been described previously as an alternative technique to provide CRT in cases where epicardial LV lead implantation is contraindicated or is at increased risk [12][13][14][15][16][17][18]. In the following paper we describe the technique that we used and the outcomes of the transseptal endocardial LV implant in patients for whom transvenous CS lead placement had failed and are not eligible for surgical epicardial implantation and have no contraindication for lifelong oral anticoagulation.…”

Section: Introductionmentioning

confidence: 99%

Transseptal Leftventricular Endocardial Pacing is an Alternative Technique in Cardiac Resynchronization Therapy. One Year Experience in a High Volume Center

Neuhoff

Szilágyi

Molnár

et al. 2016

Romanian Journal of Internal Medicine

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Introduction. In patients receiving cardiac resynchronization therapy (CRT), failure rate to implant the left ventricular (LV) lead by the traditional trans-venous approach is 4-8%. Surgical epicardial implantation is considered as an alternative, but this technique is not without morbidity. Evidence from case documentation and from small trial batches demonstrated the viability of endocardial LV lead implantation where surgical epicardial lead placement is not applicable.Material and Methods. Four patients were implanted with endocardial LV lead using the transseptal atrial approach after unsuccessful transvenous implantation. Implantation of an endocardial active fixation LV leads was successful in all patients with stable electrical parameters immediately after implantation and over the follow-up period. All patients received anticoagulation therapy in order to target the international normalized ratio of 2.5-3.5 and have not experienced any thromboembolic, hemorrhagic events, or infection.Results. Follow-up echocardiography indicated significant improvement of LV systolic function (24 + 4.9 to 32 + 5.1 %, P = 0.023) with a notable improvement of the functional status.Conclusions. Endocardial left ventricular lead implantation can be a valuable and safe alternative technique to enable LV stimulation in high surgical risk patients where standard coronary sinus implant is unsuccessful.

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“…As trial. The atrial transseptal approach has also been reported; [49][50][51] however, this technique has been limited by technical difficulties with the procedure. Overall, although LV endocardial pacing is promising for those with those patients in whom LV lead placement is not possible or CS anatomy does not provide an optimal branch location there…”

Section: Alternate Approaches To Left Ventricular Lead Placementmentioning

confidence: 99%

Developments in Cardiac Resynchronisation Therapy

Lewis

Gold

2015

Arrhythmia &Amp; Electrophysiology Review

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Since the introduction of CRT more than 20 years ago, its role in mild to severe systolic heart failure has become well established.CRT has been shown to decrease mortality, reduce heart failure hospitalisations and improve functional status in patients with NYHA class II-IV heart failure and QRS prolongation, most commonly with LBBB pattern.1 One of the major limitations of CRT implementation is the significant number of 'appropriate' candidates, as determined by guidelines, who fail to respond with clinical, functional or structural endpoints. The rate of non-responders has been estimated between 20 % and 40 %.2 Efforts to predict those patients who will respond to CRT and to optimise the magnitude of response have been important areas of focus with regard to the future of CRT. This article will present recent considerations and advances, both technical and theoretical, in CRT. 3 This trial examined 67 patients with LV ejection fraction (LVEF) ≤35 %, NYHA class III heart failure symptoms, sinus rhythm and QRS duration >150 ms who had biventricular pacemakers placed. The devices were initially programmed to ventricular back-up pacing for rates <40 beats per minute for a period of 3 months followed by reprogramming to encourage biventricular pacing. CRT resulted in significant improvement in 6-minute walk distance, quality of life and peak oxygen uptake as well as decreased hospitalisations. Eighty-five per cent of the study patients reported that they felt better during the period with biventricular pacing programmed on. BackgroundThe Multicentre InSync Randomised Clinical Evaluation (MIRACLE) trial evaluated a similar but much larger patient population. 4 There were 453 patients with NYHA class III-IV heart failure, LVEF ≤35 % and QRS duration ≥130 ms randomised to biventricular or no pacing. Over 6 months of follow-up, significant improvements were noted in 6-minute walk distance, NYHA class and quality of life. Additionally, CRT was an effective adjunct to optimal medical therapy in reducing the secondary combined endpoint of heart failure hospitalisation or death. Although the results of MUSTIC and MIRACLE were encouraging in terms of the clinical benefits of CRT, reduced mortality had not yet been proved. The Comparison of Medical Therapy, Pacing and Defibrillation(COMPANION) trial used a combined primary endpoint of hospitalisation or death from any cause.5 Enrolling 1,520 patients with LVEF ≤35 %, NYHA class III-IV heart failure and QRS duration >120 ms, this trial randomised subjects to optimal medical therapy, medical therapy with a CRT pacemaker (CRT-P) or medical therapy with a CRT defibrillator (CRT-D). At 1 year of follow-up, the CRT-D group showed significant reduction in overall mortality versus medical therapy alone, and the CRT-P group had showed a strong trend for reduced mortality (p=0.059).These results suggested a mortality benefit from CRT even in the absence of defibrillator capabilities.Several studies have since examined the effects of biventricular pacing alone (i.e. CRT-P) on heart fa...

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Biventricular ICD implant using endocardial LV lead placement from the left subclavian vein approach and transseptal puncture via the transfemoral route

Cited by 28 publications

References 3 publications

Development of a Technique for Left Ventricular Endocardial Pacing via Puncture of the Interventricular Septum

Development of a Technique for Left Ventricular Endocardial Pacing via Puncture of the Interventricular Septum

Transseptal Leftventricular Endocardial Pacing is an Alternative Technique in Cardiac Resynchronization Therapy. One Year Experience in a High Volume Center

Developments in Cardiac Resynchronisation Therapy

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