Modified snare technique improves left ventricular lead implant success for cardiac resynchronization therapy

Abstract

Background Left ventricular (LV) lead placement is the most challenging aspect of cardiac resynchronization therapy (CRT) device implantation, with a failure rate of up to 10% due to complex coronary anatomies. We describe a modified snare technique for LV lead placement and evaluate its safety and efficacy in cases when standard methods fail. Methods and Results A prospective study was conducted of patients indicated for a CRT implant. When LV lead delivery to the target vessel failed using standard techniques, a modified snare technique was employed. Patients were evaluated every 6 months. From 2015 to 2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow‐up duration 18.9 ± 15.8 months). The standard LV implant technique failed in 94 cases (16.6%), of which the modified snare technique was successful in 92 (97.9%). There were no differences between the modified snare and standard techniques in the rates of 30‐day postimplant CRT all‐cause mortality (3.2% vs. 1.7%, p = .33), 4‐year all‐cause mortality (15.9% vs. 15.5%, p = .49), or major acute complications (7.4% vs. 3.8%, p = .12). However, the 4‐year procedural reintervention rate was lower with the modified snare technique (3.2% vs. 10.2%, p < .05), specifically LV implant failure or dislodgement rates (0% vs. 5.3%, p < .05), improving the response rate (71.8% vs. 55.1%, p < .05). Conclusions For challenging coronary sinus anatomies that preclude LV lead placement by standard methods, this modified snare alternative was safe and effective, with comparable mortality and complications, but significantly lower procedural reintervention and higher response rates.

Retrograde Snaring for Left Ventricular Lead Placement in the Presence of a Persistent Left Superior Vena Cava

“…10 A modification to the Worley snare technique-in which a secondary CS sheath is introduced to deliver the snare-was shown to improve lead traction and promote LV lead delivery in the event of narrow or tortuous vascular anomalies. 16 Utilization of the snare technique in patients undergoing LV lead placement in the presence of a PLSVC has not been widely reported. 17 Our case lends further support to the use of this approach to assist in the placement of the LV lead in patients with anatomical variants, such as a PLSVC.…”

Clinical impact of MultiPoint pacing in responders to cardiac resynchronization therapy

“…CS delivery sheath selection was not limited to a specific manufacturer, but the Attain Command (Medtronic, Minneapolis, MN, USA) and Selectra (Biotronik, Berlin, Germany) were preferentially chosen. If narrow, tortuous, or otherwise complex vascular anatomies precluded LV lead delivery to the target vessel using standard techniques, a modified snare technique was used as an alternative 7 …”

“…Patient‐specific optimization of the LV pacing site has been shown to have a significant impact on CRT outcomes 6 . Consequently, methods have been developed to improve CRT response rate by targeting LV pacing sites of interest, including novel techniques to enable LV lead implantation in small tributary coronary vessels, 7 or the use of electro‐anatomical mapping to guide LV lead placement based on electrical activation times 8–10 . Specifically, pacing from the latest activating LV tissue has been associated with a greater increase in contractility 11 and significantly higher CRT response rate 12 .…”