Left Ventricular Endocardial Pacing Techniques as an Alternative for Ineffective Cardiac Resynchronization Therapy and the Role of Acute Hemodynamic Evaluation

Gelder, Berry M. van; Houthuizen, Patrick; Scheffer, M; Dekker, Lukas; Bracke, Frank

doi:10.5772/13140

Cited by 2 publications

(6 citation statements)

References 33 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%

“…[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. Although femoral arterial access was used for left ventriculography and coronary angiography, this could potentially be performed through radial arterial access, or avoided completely as experience grows, or other imaging techniques such as intracardiac or transesophageal echocardiography are used.…”

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%

“…9,12,13,20,22,23 During the development of the ventricular transseptal puncture technique, it was found that use of a guidewire combined with radiofrequency energy facilitated a quicker procedure with a more basal or midseptal puncture site. The use of diathermy energy from an electrocautery pen delivered through a Brockenbrough needle has previously been described to facilitate atrial transseptal puncture.…”

mentioning

confidence: 99%

“…12,[20][21][22] Embolic events in atrial transseptal lead patients have been ascribed to subtherapeutic anticoagulation. 12,20,22,23 The lack of residual flow across the ventricular septum, combined with the absence of lead in the low-pressure left atrial chamber, where lead thrombi are more likely to form, may make lead thrombosis or paradoxical emboli less likely than with the atrial transseptal route.24 Despite this all LV endocardial pacing is limited by the presence of a lead in the systemic circulation and the resultant need for lifelong anticoagulation, unless new technologies can safely eliminate the risk of thrombus formation. The risk-benefit ratio of anticoagulation in patients with heart failure is finely balanced and may make this approach inappropriate in some patients.…”

mentioning

confidence: 99%

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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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