Technical Aspects of Implantation of LV Lead for Cardiac Resynchronization Therapy in Chronic Heart Failure

Abstract

The goal of this study was to analyze total procedural and fluoroscopic time during initial experience with implantation of LV lead in a single center, and to assess the performance of electrophysiologically-guided approach for cannulation of the coronary sinus (CS) in a subsequent period. Over an initial period of 29 months, a total of 46 attempts to implant biventricular pacing system were revised. During the first phase, only one type of LV electrode was available for three implanters (11 attempts). The second phase covered their early experience with other stylet-controlled LV leads (10 attempts). Additional LV leads including the over-the-wire design were available in the third phase and 25 attempts were done by he most experienced implanter. In a period of advanced experience, 92 implant procedures performed by four implanters using an electrophysiologically-guided approach to CS cannulation were revised. In the first period, success rates for different phases reached 70%, 90%, and 96%, respectively. Significant decrease in both procedural and fluoroscopic times was achieved with increased experience (Phase I: 247.1 +/- 104.5 minutes and 31.2 +/- 34.3 minutes, Phase II: 219.4 +/- 85.6 minutes, and 22.9 +/- 19.1 minutes, Phase III: 116.4 +/- 89.9 minutes and 6.6 +/- 4.4 minutes, respectively, P < 0.05). Advanced experience with electrophysiologically-guided approach to CS cannulation allowed achievement of this target within a reasonable amount of time (15.4 +/- 16.3 minutes) and with minimum fluoroscopic time (2.1 +/- 2.9 minutes). In conclusion, both individual learning curve and technical advances significantly influence success rate, procedural, and fluoroscopic times for biventricular system implantation. Electrophysiologically-guided approach makes cannulation of the CS a highly reproducible procedure that requires minimum fluoroscopic time.

Implantation Techniques of Leads for Left Ventricular Pacing in Cardiac Resynchronization Therapy and Electrocardiographic Consequences of the Stimulation Site

“…Implantation training for CRT has a significant learning curve. Duration of implantation and fluoroscopic time will greatly reduce with experience ( Kautzner et al,2004).Implantation failure is due to inability to intubate the CS, unstable guiding delivery catheter, absence of suitable side branches in the postero-lateral region, coronary vein stenosis or occlusion, lead instability, high stimulation threshold, phrenic nerve stimulation or a combination of the above (Bentkover et al,2003;Gras et al,2002). Success depends on multiple factors including operator's experience and technique, individual anatomy of the CS, threshold and phrenic nerve stimulation regions and available instrumentation and leads.…”

“…In case of an absent cephalic vein double or triple puncture of the subclavian or axillary vein is used to introduce separate sheaths for the three leads. The RV lead is first implanted to provide backup pacing in case of traumatizing the right bundle in patients with preexisting left bundle branch block or due to traumatic atrioventricular block with introduction of the guiding catheter in the CS, which occur in 1-4% of cases (Abraham et al,2002;Kautzner et al,2004) (Fig 3). Fig.…”

Aspectos técnicos do implante de eletrodo para estimulação ventricular esquerda através do seio coronariano, com a utilização de anatomia radiológica e eletrograma intracavitário, na terapia de ressincronização cardíaca

“…The success of the implantation depends on multiple variables, including experience and technique of the surgeon, anatomy of the coronary sinus and availability and variety of special materials [6].…”

“…The second is that, eventually, patients present with a persistent left vena cava with atresia of the coronary sinus ostium [14,15], making implantation to the right impossible. We chose to implant conventional electrodes for right ventricular and atrial pacing, respectively, as they serve as points of [301][302][303][304][305][306][307][308][309] anatomical definition and because, during the manipulation of the electrode in the patients with blocks of the left branch, there is a risk of injury to the right branch, causing total atrioventricular blocks and the necessity of temporary cardiac pacing, as has been described in the literature [6] and which occurred in two of our patients.…”

“…The impossibility of CS catheterization, variations in the anatomy of coronary venous system and diaphragmatic pacing are the most common reasons for lead placement to be unsuccessful. Failure rates tend to decrease with the development of new electrodes and the surgeon's experience [6][7][8][9].…”