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Neragi-Miandoab S. A ventricular assist device as a bridge to recovery, decision making, or transplantation in patients with advanced cardiac failure. Surg Today 2012; 42:917-26. [DOI: 10.1007/s00595-012-0256-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 02/13/2012] [Indexed: 01/07/2023]
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Suzuki S, Furui S, Yamakawa T, Isshiki T, Watanabe A, Iino R, Kidouchi T, Nakano Y. Radiation exposure to patients' skin during cardiac resynchronization therapy. Europace 2009; 11:1683-8. [DOI: 10.1093/europace/eup302] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Schwierz T, Winter S, Pürerfellner H, Tomaselli F, Nesser HJ, Függer R. N.-phrenicus-Stimulation bei biventrikulären Schrittmachern. Chirurg 2007; 78:1037-40. [PMID: 17579820 DOI: 10.1007/s00104-007-1368-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Phrenic nerve stimulation (PNS) complicates the positioning of the left ventricle lead. We present a step-by-step approach to correct PNS during implantation, as established in our daily routine. METHODS The incidence of PNS, its successful correction, and long-term results (median 27 months) were analyzed retrospectively in 266 lead positions. RESULTS Phrenic nerve stimulation occurred in 13.9% of the lead positions. Multivariate analysis (P<0.02) showed that PNS only depended on the place of stimulation (coronary sinus side branch). Lead type, CRT indication, and patient's sex had no significant correlation. Following the step-by-step approach presented here, PNS was corrected satisfactorily in all cases. CONCLUSIONS Approach in case of PNS: 1. push or pull the lead within the same vein, 2. change to a different vein, 3. maintain position in case of a safe distance between the phrenic nerve and the pacing threshold, 4. change the lead type to achieve stable anchorage at adequate positions, 5. use a device featuring electronic repositioning.
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Affiliation(s)
- T Schwierz
- Chirurgische Abteilung, Allgemeines öffentliches Krankenhaus der Elisabethinen, Fadingerstrasse 1, Linz, Austria.
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Hoppe UC. Resynchronization therapy in the context of atrial fibrillation: Benefits and limitations. J Interv Card Electrophysiol 2007; 18:225-32. [PMID: 17450330 DOI: 10.1007/s10840-007-9092-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2006] [Accepted: 02/15/2007] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation (AF) and heart failure often coexist and are believed to directly predispose to each other. Cardiac resynchronization does not prevent or increase the induction of AF. However, new onset of AF does not seem to diminish the beneficial effects of CRT on symptoms, cardiac function and, more importantly, all-cause mortality if appropriate ventricular rate control by beta-blockers and digoxin is being achieved. While a pharmacological approach to control ventricular rate may be sufficient in most patients with paroxysmal AF or AF of shorter duration in those with permanent AF ablation strategies may be necessary. Observational studies and one randomized trial indicate a potential benefit of CRT in heart failure patients with chronic AF; particularly, biventricular pacing was superior compared to conventional right-univentricular stimulation. However, recent results suggest that even relatively high percentage biventricular capture may be inadequate, and that the benefits of CRT may only be extended to chronic AF patients with previous AV junctional ablation. Well designed and powered clinical trials are required before pacemaker dependency is created in large numbers of heart failure patients.
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Affiliation(s)
- Uta C Hoppe
- Department of Internal Medicine III, University of Cologne, Kerpener Str. 62, Cologne, Germany.
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Byrd IA, Kay MW, Pollard AE. Interactions between paced wavefronts and monomorphic ventricular tachycardia: implications for antitachycardia pacing. J Cardiovasc Electrophysiol 2006; 17:1129-39. [PMID: 16989652 DOI: 10.1111/j.1540-8167.2006.00579.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Interactions between paced wavefronts and monomorphic ventricular tachycardia (VT) dictate antitachycardia pacing outcomes. We used optical mapping to assess those interactions during single and dual site pacing of rabbit ventricular epicardium. METHODS AND RESULTS Monomorphic VTs were initiated in six isolated rabbit hearts that were endocardially cryoablated to limit viable tissue to visible epicardium and establish apical tissue as the anatomic anchor. Preparations were optically mapped during single (n = 39) and dual (n = 43) site pacing at 50%-90% of VT cycle length (CL) with eight pulses per trial. Overall, we found six pulses that abruptly terminated VT. This occurred because the VT wavefront collided with the antidromic portion of the paced wavefront and the orthodromic portion of paced wavefront blocked in the VT's refractory region. When effective, dual site pacing that captured tissue at both leads simultaneously terminated the VT immediately, while single site pacing or dual site pacing that captured tissue at only one lead terminated the VT after resetting advanced the orthodromic wavefront. We found 12 pulses that induced polymorphic VT, with 11 of those pulses occurring during capture at only one lead. Expansion of the combined antidromic-VT wavefront around one or both ends of the arc of conduction block formed by the interaction of the orthodromic wavefront with the VT's refractory region initiated functional reentry. Six of these polymorphic VTs were nonsustained because the underlying wavefronts self-terminated. The wavefronts did persist for 4.2 +/- 3.5 cycles before self-terminating in these trials, and the post-pacing cycles presented a 146% increase in CL variability, compared with the variability prior to pacing. These temporal characteristics are similar to those of delayed termination in patients with ICDs. CONCLUSIONS The main difference between pulses that terminated abruptly and pulses that induced polymorphic VT was the effective separation of the antidromic and orthodromic portions of the paced wavefront from one another.
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Affiliation(s)
- Israel A Byrd
- Cardiac Rhythm Management Laboratory, Department of Biomedical Engineering, University of Alabama at Birmingham, Alabama 35294, USA
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Barold SS, Giudici MC, Herweg B, Curtis AB. Diagnostic Value of the 12-Lead Electrocardiogram during Conventional and Biventricular Pacing for Cardiac Resynchronization. Cardiol Clin 2006; 24:471-90, x. [PMID: 16939837 DOI: 10.1016/j.ccl.2006.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The paced 12-lead ECG is a valuable tool in the assessment of patients with pacemakers, and ideally should be recorded routinely at the time of implantation and during follow-up. It has become particularly important in patients undergoing cardiac resynchronization. The multiplicity of clinical situations described in this review highlight the pitfalls of using a single ECG lead in the overall evaluation of pacemaker patients. The design of programmers capable of registering a 12-lead ECG would obviate the need of an additional electrocardiograph and encourage the routine recording of the paced 12-lead ECG with each patient encounter. Such an arrangement would improve the care of pacemaker patients.
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Affiliation(s)
- S Serge Barold
- Division of Cardiology, University of South Florida College of Medicine and Tampa General Hospital, Tampa, FL 33615, USA.
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Rivero-Ayerza M, Thornton AS, Theuns DAMJ, Scholten MF, Mekel JM, Res J, Jordaens LJ. Left Ventricular Lead Placement Within a Coronary Sinus Side Branch Using Remote Magnetic Navigation of a Guidewire: A Feasibility Study. J Cardiovasc Electrophysiol 2006; 17:128-33. [PMID: 16533248 DOI: 10.1111/j.1540-8167.2005.00313.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND A novel magnetic navigation system (MNS) allowing remote guidance of catheters and guidewires might assist in implantation of left ventricular (LV) pacing leads. OBJECTIVE To assess the feasibility of deploying a LV pacing lead into a coronary sinus (CS) side branch using a magnetically guided wire and of performing the procedure without a CS guiding sheath. METHODS Twenty-one patients were included in this study. Nine underwent CRT device implantation using a MNS to steer the guidewire (MNS group) while 12 patients were conventionally implanted (control group). In 6 patients in the MNS group, the procedure was performed using a CS guiding sheath. In 3 others, the decision was to perform the procedure without a CS sheath. In these patients the wire was advanced manually, while the external magnets oriented it toward the CS os. In the CS, "vector based" navigation was used to guide the wire to the desired side branch. RESULTS In all 9 patients in the MNS group, the target vessel could be successfully engaged by the magnetically guided wire. In 7, the LV lead was lodged in the target vessel. In 2 patients, the LV lead was repositioned in an anterolateral side branch due to instability or inability to engage the vessel with it. Mean total procedure time was 164 +/- 58 minutes (without sheath 229 +/- 52 vs with sheath 132 +/- 26 minutes; P = 0.007). Mean fluoroscopy time was 28 +/- 9 minutes. For control patients, the procedure and fluoroscopy time were similar (144 +/- 41 minutes and 26 +/- 12 minutes, respectively). No major complications occurred. CONCLUSION LV lead implantation can be performed using a remote magnetically steered guidewire. Though the lead could be implanted without a CS guiding sheath, longer procedure times were required.
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Affiliation(s)
- Maximo Rivero-Ayerza
- Department of Clinical Electrophysiology, Thoraxcenter - Erasmus MC, Rotterdam, The Netherlands.
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Sánchez-Quintana D, Cabrera JA, Climent V, Farré J, Weiglein A, Ho SY. How close are the phrenic nerves to cardiac structures? Implications for cardiac interventionalists. J Cardiovasc Electrophysiol 2005; 16:309-13. [PMID: 15817092 DOI: 10.1046/j.1540-8167.2005.40759.x] [Citation(s) in RCA: 179] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Phrenic nerve injury is a recognized complication following cardiac intervention or surgery. With increasing use of transcatheter procedures to treat drug-refractory arrhythmias, clarification of the spatial relationships between the phrenic nerves and important cardiac structures is essential to reduce risks. METHODS AND RESULTS We examined by gross dissection the courses of the right and left phrenic nerves in 19 cadavers. Measurements were made of the minimal and maximal distances of the nerves to the superior caval vein, superior cavoatrial junction, right pulmonary veins, and coronary veins. Histologic studies were carried out on tissues from six cavaders. Tracing the course of the right phrenic nerve revealed its close proximity to the superior caval vein (minimum 0.3 +/- 0.5 mm) and the right superior pulmonary vein (minimum 2.1 +/- 0.4 mm). The anterior wall of the right superior pulmonary vein was <2 mm from the right phrenic nerve in 32% of specimens. The left phrenic nerve passed over the obtuse cardiac margin and the left obtuse marginal vein and artery in 79% of specimens. In the remaining specimens, its course was anterosuperior, passing over the main stem of the left coronary artery or the anterior descending artery and great cardiac vein. CONCLUSIONS The right phrenic nerve is at risk when ablations are carried out in the superior caval vein and the right superior pulmonary vein. The left phrenic nerve is vulnerable during lead implantation into the great cardiac and left obtuse marginal veins.
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Abstract
Multisite pacing for the treatment of heart failure has added a new dimension to the electrocardiographic evaluation of device function. During left ventricular (LV) pacing from the appropriate site in the coronary venous system, a correctly positioned lead V1 registers a right bundle branch block pattern with few exceptions. During biventricular stimulation associated with right ventricular (RV) apical pacing, the QRS is often positive in lead V1. The frontal plane QRS axis is usually in the right superior quadrant and occasionally in the left superior quadrant. Barring incorrect placement of lead V1 (too high on the chest), lack of LV capture, LV lead displacement or marked latency (exit block or delay from the stimulation site), ventricular fusion with the spontaneous QRS complex, a negative QRS complex in lead V1 during biventricular pacing involving the RV apex probably reflects different activation of an heterogeneous biventricular substrate (ischemia, scar, His-Purkinje participation in view of the varying patterns of LV activation in spontaneous left bundle branch block) and does not necessarily indicate a poor (electrical or mechanical) contribution from LV stimulation. In this situation, it is imperative to rule out the presence of coronary venous pacing via the middle cardiac vein or even unintended placement of two leads in the RV. During biventricular pacing with the RV lead in the outflow tract, the paced QRS in lead V1 is often negative and the frontal plane paced QRS axis is often directed to the right inferior quadrant (right axis deviation). In patients with sinus rhythm and a relatively short PR interval, ventricular fusion with competing native conduction during biventricular pacing may cause misinterpretation of the ECG because narrowing of the paced QRS complex simulates appropriate biventricular capture. This represents a common pitfall in device follow-up. Elimination of ventricular fusion by shortening the AV delay, is often associated with clinical improvement. Anodal stimulation may complicate threshold testing and should not be misinterpreted as pacemaker malfunction. One must be cognizant of the various disturbances that can disrupt 1:1 atrial tracking and cause loss of ventricular resynchronization. (1) Upper rate response. The upper rate response of biventricular pacemakers differs from the traditional Wenckebach upper rate response of conventional antibradycardia pacemakers because heart failure patients generally do not have sinus bradycardia or AV junctional conduction delay. The programmed upper rate should be sufficiently fast to avoid loss of resynchronization in situations associated with sinus tachycardia. (2) Below the programmed upper rate. This may be caused by a variety of events (especially ventricular premature complexes and favored by the presence of first-degree AV block) that alter the timing of sensed and paced events. In such cases, atrial events become trapped into the postventricular atrial refractory period at atrial rates below the programmed upper rate in the presence of spontaneous AV conduction. Algorithms are available to restore resynchronization by automatic temporary abbreviation of the postventricular atrial refractory period.
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Affiliation(s)
- S Serge Barold
- Cardiology Division, University of South Florida College of Medicine and Tampa General Hospital, Tampa, FL, USA.
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Fisher JD, Garcia J, Kim SG, Ferrick KJ, Palma EC, Crooke G, Moskowitz R, Lejemtel T. Easy Surgical Approach for Completion of Biventricular Pacing. J Cardiovasc Electrophysiol 2004; 15:1462-3. [PMID: 15610297 DOI: 10.1046/j.1540-8167.2004.04065.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Placement of a pacing lead into a branch of the coronary sinus for biventricular pacing sometimes is difficult or impossible. Surgical completion typically has included immediate or subsequent thoracotomy lead placement with hookup to the device at the time of chest surgery. We describe an alternative procedure of complete device-lead hookup and permanent pocket closure in the electrophysiology laboratory. The left ventricular lead is an epicardial type. The lead is tunneled to a position where the surgeon subsequently can recover it using the thoracotomy incision and implant the lead on the epicardium using device-based testing.
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Affiliation(s)
- John D Fisher
- Department of Medicine, Cardiology Division, Arrhythmia and Heart Failure Services, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York 10467, USA.
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Ross HM, Kocovic DZ. Cardiac resynchronization therapy for heart failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2004; 6:365-370. [PMID: 15324612 DOI: 10.1007/s11936-004-0020-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cardiac resynchronization therapy has been established as important adjuvant therapy in the treatment of severe heart failure. As lead delivery systems have improved and the number of experienced implanters has increased, more patients have access to transvenous left ventricular lead implantation, outside of clinical trials at large medical centers. Ongoing research continues to perfect implantation techniques to optimize patient outcomes, as well as develop hardware and software technology used in implanted devices. Resynchronization therapy typically results in a decreased burden of emergency room visits and hospitalizations for decompensated heart failure. In addition, diagnostic tools available in resynchronization devices allow clinicians to not only predict heart failure decompensation and adjust medical therapies accordingly, but they also allow for the diagnosis of asymptomatic arrhythmias that may predict adverse outcomes, as well as allow for the diagnosis of symptomatic arrhythmias without the need for additional costly workup. This suggests that in the long term, biventricular device implantation may actually provide cost savings to the health care system. On a macroeconomic scale, there are significant concerns about the cost burden to society of increased implantation of resynchronization therapy devices, along the same lines as concerns raised regarding the expanding indications for implantable cardioverter-defibrillator implantation. As future research broadens indications for implanting implantable cardioverter-defibrillators, as well as resynchronization systems, we may see cardiac resynchronization therapy become a secondary prevention tool yielding long-term patient benefits by postponing or preventing a decline in heart failure status.
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Affiliation(s)
- Heather M. Ross
- Main Line Health Heart Center, 556 Lankenau Medical Office Building East, 100 Lancaster Avenue, Wynnewood, PA 19096, USA.
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