Novel Doppler‐guided subxyphoid approach to avoid coronary artery damage during left ventricular epicardial lead placement or ablation

Abstract

Background Subxyphoid active left ventricular epicardial (LVE) lead implants or VT ablation are attractive but remain a challenge due to concerns of coronary artery damage. We aimed to see if Doppler‐guided positioning could permit safe LVE lead placement without coronary angiography. We evaluated the feasibility of a Doppler flow‐guided subxyphoid epicardial screw‐in lead fixation in a swine model. Methods Acute subxyphoid access to the pericardial space was performed in an anesthetized swine model using a deflectable sheath and a modified needle‐derived Doppler flow meter. The audio signal and visual display from the Doppler flow meter were recorded. Coronary angiography was performed to verify the catheter location. A SelectSecure Model 3830 lead (Medtronic) was used to assess pacing in the procedure. Results In both of two swine, the deflectable catheter was inserted into pericardial space via subxyphoid access. The tip of the deflectable catheter with the Doppler was directed to several locations, from quiet (no nearby coronary artery expected) to typical rhythmic pulsatile sound locations which were maximal when superimposed on a coronary artery. Repeated coronary angiograms confirmed the expected findings. A 3830 active lead was fixed into a quiet location for LVE pacing, and confirmed by angiography as distant from a coronary artery. Conclusions Doppler‐guided subxyphoid epicardial screw‐in lead placement is feasible once the catheter tip is directed and stabilized in a desired LVE location. This obviates the need for repeated (or any) coronary angiography. The Doppler‐guided subxyphoid epicardial procedure may also be applicable for epicardial ventricular arrhythmia ablation procedures.

Epicardial implantation of a lumenless active fixation lead in a neonate

“…The previous literature has reported rare cases of epicardial implantation of Model 3830. Fisher JD et al 4 . verified the feasibility of Model 3830 implantation into the epicardium in swine, and their study also proved that it can be implanted without damage to the coronary vessels.…”

“…Fisher JD et al 4 verified the feasibility of Model 3830 implantation into the epicardium in swine, and their study also proved that it can be implanted without damage to the coronary vessels. Our team has less experience with epicardial implantation of dual-chamber pacemakers in neonates, and guidelines do not recommend dual-chamber pacemakers for this population, 2 so we did not choose a dual-chamber pacemaker.…”