Reversing cardiac resynchronization therapy non-responder status in a patient with a surgically placed epicardial left ventricular lead by switching to an active fixation coronary sinus lead

Abstract

puncture. Both the patients improved haemodynamically after the activation of IABP, and the implantations were successfully completed other than the epicardially implanted LV lead in Case 1. No other procedure-related complications were observed.In conclusion, activation of IABP may be a safe and beneficial option for completing the procedure in patients experiencing acute heart failure worsening during CRT implantation. This approach could eliminate both the need for re-operation and diminish the associated risks. Reversing cardiac resynchronization therapy non-responder status in a patient with a surgically placed epicardial left ventricular lead by switching to an active fixation coronary sinus lead This report describes the reversal of a cardiac resynchronization therapy non-responder status in a patient with a surgically placed left ventricular lead by the use of a newly available active fixation coronary sinus lead. Case reportWe report on a 55-year-old man with dilated cardiomyopathy. His left ventricular ejection fraction (LVEF) was 18% at the first presentation. He was in New York Heart Association (NYHA) stage III, despite of optimized medical therapy. Heart transplantation was considered as an option, but the patient also showed a complete left bundle brunch block. Therefore, he received a cardiac resynchronization therapy (CRT) defibrillator system in June 2006. Two dislocations of the coronary sinus (CS) lead occurred and, finally, a surgical approach was chosen. An epicardial (EPI) left ventricular (LV) lead was placed via left lateral thoracotomy. As the patient's condition did not improve (NYHA class III, brain natriuretic peptide (BNP) levels 3800 pg/mL, and LVEF 15%) during the next months, he was admitted for further evaluation. The pacemaker check revealed normal sensing and pacing thresholds, and his electrocardiogram appeared to show biventricular pacing with a reduction in the QRS width by 30 ms. Tissue Doppler imaging revealed the presence of asynchrony, despite formal correct biventricular pacing.

Strategy for Failed Transvenous Left-Ventricular Lead Placement in Cardiac Resynchronization Therapy: Surrender or Struggle?

“…The improvement in mortality, heart function, and quality of life associated with CRT in selected patients with symptomatic HF and interventricular conduction delay has been well established [3-7]. Transvenous LV lead placement is currently considered the first-line approach for CRT but is unsuccessful in up to 5% of patients [8, 9]. Factors leading to the failure of transvenous LV lead placement include the inability to cannulate the CS, the absence of suitable venous tributaries, and complications including lead dislodgement, electrode malpositioning, CS dissection, and unpredictable phrenic-nerve stimulation [8, 9].…”

“…Transvenous LV lead placement is currently considered the first-line approach for CRT but is unsuccessful in up to 5% of patients [8, 9]. Factors leading to the failure of transvenous LV lead placement include the inability to cannulate the CS, the absence of suitable venous tributaries, and complications including lead dislodgement, electrode malpositioning, CS dissection, and unpredictable phrenic-nerve stimulation [8, 9]. Even with successful implantation, nearly 30% of current CRT recipients failed to derive a benefit from the device yet beyond the postprocedural period [12].…”

“…In addition to providing a means of salvaging a successful CRT, surgical LV lead placement offers the freedom of manoeuvring the LV lead without anatomic restriction and theoretically leads to a higher response rate among CRT candidates. However, the majority of the studies indicated that there was no demonstrable superiority of outcomes for patients implanted with LV leads surgically compared to those implanted the conventional transvenous way [8, 15-17]. The reason for the discrepancy between the theoretical and practical results remains unclear.…”

“…The transvenous approach, mainly via the trans-coronary-sinus (CS), is the most commonly applied approach to perform left-ventricular (LV) lead placement. However, up to 5% of the implantations are unsuccessful due to anatomical barriers, periprocedural complications, high pacing thresholds, or phrenic-nerve stimulation [8, 9]. Even with the successful engagement of the CS, only 47–63% of LV leads were placed at optimal sites, which are considered to be the latest activation area of the LV as evaluated by a single-photon emission computed tomography scan [10, 11].…”

“…Surgical intervention is one of the most important alternative approaches to achieve CRT [13, 14]. Most of the previous studies demonstrated that the clinical outcomes of CRT recipients with epicardial LV leads were comparable with those of patients with transvenous LV leads [8, 15-17]. In such situations, the LV lead is often placed empirically at the lateral wall of the LV epicardium only to avoid the vessels and phrenic nerve.…”