First experience with a new active fixation coronary sinus lead

UK multicenter retrospective comparison of novel active versus conventional passive fixation coronary sinus leads

BACKGROUND

A novel active fixation coronary sinus (CS) lead, Attain Stability (AS), has been released aiming to improve targeted lead positioning. Rather than being wedged into the distal vessel, it relies on a side helix for fixation. We aimed to compare implant procedure parameters and electromechanical stability of the AS lead with passive CS leads.

METHODS

A retrospective study involving six major UK cardiac centers. Patients who received active fixation leads were compared with passive fixation lead recipients in a 1:2 ratio. The primary outcome was total lead displacements (combined macrodisplacement/microdisplacement, defined as displacements requiring repositioning procedures, an increase in threshold ≥0.5 V or pulse width ≥0.5 ms, or a change in pacing polarity).

RESULTS

A total of 761 patients were included (253 AS leads and 508 passive fixation leads), of which 736 had follow-up data. The primary endpoint rate was 31% (75/241) in the active and 43% (214/495) in the passive group (p = .002). Six patients (2.5%) in the active group and 14 patients (2.8%) in the passive group required CS lead repositioning procedures (p = 0.981). On multivariable analysis, active leads were associated with a reduction in lead displacements, odds ratio 0.66 (95% confidence interval: 0.46-0.95), p = .024. There were differences in favor of passive leads in procedure duration, 120 (96-149) versus 127 (105-155) min (p = .008), and fluoroscopy time, 17 (11-26) versus 18.5 (13-27) min (p = .0022). The median follow-up duration was similar (active vs. passive): 31 (17-47) versus 34 (16-71) weeks, (p = .052).

CONCLUSION

AS CS leads had improved electromechanical stability compared with passive fixation leads, with only minimal increases in implant procedure and fluoroscopy times.

Coronary Sinus Lead Removal: A Comparison between Active and Passive Fixation Leads

Background

Implantation of coronary sinus (CS) leads may be a difficult procedure due to different vein anatomies and a possible lead dislodgement. The mode of CS lead fixation has changed and developed in recent years.

Objectives

We compared the removal procedures of active and passive fixation leads.

Methods

Between January 2009 and January 2014, 22 patients at our centre underwent CS lead removal, 6 active and 16 passive fixation leads were attempted using simple traction or lead locking devices with or without laser extraction sheaths. Data on procedural variables and success rates were collected and retrospectively analyzed.

Results

The mean patient age was 67.2 ± 9.8 years, and 90.9% were male. The indication for lead removal was infection in all cases. All active fixation leads were Medtronic^® Attain StarFix^™ Model 4195 (Medtronic Inc., Minneapolis, MN, USA). The mean time from implantation for the active and passive fixation leads was 9.9 ± 11.7 months (range 1.0–30.1) and 48.7 ± 33.6 months (range 5.7–106.4), respectively (p = 0.012). Only 3 of 6 StarFix leads were successfully removed (50%) compared to 16 of 16 (100%) of the passive fixation CS leads (p = 0.013). No death or complications occurred during the 30-day follow-up.

Conclusion

According to our experience, removal of the Starfix active fixation CS leads had a higher procedural failure rate compared to passive.

Starfix lead extraction: Clinical experience and technical issues

Transvenous lead extraction (TLE) of the Starfix coronary sinus (CS) active-fixation lead may be challenging, due to undeployment of fixation lobes and venous occlusion. We report our experience in Starfix TLE, in comparison with previous data. A 78-year-old male, implanted in 2009 with Starfix lead, was referred to our institution for TLE, due to infective endocarditis with lead-associated vegetations. The tip of Starfix lead was located in distant, anterior position, in the great cardiac vein, close to patent left internal mammary artery-to-left anterior descending artery anastomosis, and first-choice surgical removal had a prohibitive operative risk. Conventional dilatation beyond CS ostium, as well as the use of a standard delivery catheter, was ineffective. An off-label modification of the delivery, by cutting the distal soft tip, was successful. However, the tip of the lead fragmented and was trapped in the innominate vein. Then a gooseneck snare grasped the fragment, allowing complete retrieval. TLE of Starfix leads may be particularly challenging, especially when its tip is located in a distant anterior location. In these cases, important help may be obtained by dilatation within the CS, by means of conventional or modified delivery catheters. Only experienced operators, sometimes with non-conventional techniques, should perform TLE of Starfix leads. .

Multicenter experience with transvenous lead extraction of active fixation coronary sinus leads

BACKGROUND/OBJECTIVE

Active fixation coronary sinus (CS) leads limit dislodgement and represent an attractive option to the implanter. Although extraction of passive fixation CS leads is a common and frequently uncomplicated procedure, data regarding extraction of chronically implanted active fixation CS leads are limited.

METHODS

We performed a retrospective cohort study of patients undergoing active fixation CS lead extraction at six centers. Patient and procedural characteristics, indications for extraction, use of extraction sheath (ES) assistance, and outcomes are reported.

RESULTS

Between January 2009 and February 2011, 12 patients underwent transvenous lead extraction (TLE) of Medtronic StarFix® lead (Medtronic Inc., Minneapolis, MN, USA). The cohort was 83% male with mean age 71 ± 14 years. Average implant duration was 14.2 ± 5.7 months (2.3-23.6). All leads but one were removed for infectious indications (67% systemic infection). At the time of explant, the fixation lobes were completely retracted in only one of the 12 cases and ES assistance was required for lead removal in all cases (58% laser, 25% cutting, 25% mechanical, and 25% femoral). The majority of cases required advancement of the sheath into the CS (75.0%) and often into a branch vessel (41.7%). One lead could not be removed transvenously and required surgical lead extraction. There were no major complications. Examination of the leads after extraction frequently revealed significant tissue growth into the fixation lobes.

CONCLUSIONS

Although TLE of active fixation CS leads can be a safe procedure in select patients and experienced hands, powered sheaths and aggressive techniques are frequently required for successful removal despite relatively short implant durations. This raises significant concern regarding future TLE of active fixation CS leads with longer implant durations.

Outcomes and predictors of difficulty with coronary sinus lead removal

With increasing coronary sinus (CS) pacemaker leads for cardiac resynchronization therapy, the need to remove these leads has risen. The purpose of this study is to describe a single center's experience with CS lead removal and to attempt to identify predictors of difficulty with lead removal and complications. We reviewed all percutaneous endocardial CS lead removals performed at our institution through February 2010. Successful removal with traction alone was considered simple while complex extractions required traction devices and/or laser sheaths. Between December 1996 and February 2010, 125 CS leads were percutaneously removed ≥1 week post-implantation from 115 patients. One attempt at CS lead extraction was unsuccessful. The average duration since implantation for the CS leads was 1.54 years (± .75 years, range 8 days to 8.24 years). The majority of the leads were removed by simple traction (n = 114, 91.2 %). The remainder were removed by femoral approach with snare (n = 3, 2.4 %), locking stylet (n = 2, 1.6 %), or locking stylet and laser sheath (n = 6, 4.8 %). Half of CS leads in place greater than 4 years required complex extraction (n = 7/14, 50 %). CS complications (n = 11 patients, 8.8 %) included CS or tributary thrombosis (n = 7/102, 6.9 %) and CS dissection (n = 4/102, 3.9 %). Major non-CS complications (n = 2 patients, 1.6 %) included a cardiac tear requiring pericardiocentesis and thoracotomy (n = 1, 0.8 %) and subclavian vein tear requiring surgical repair (n = 1, 0.8 %). Minor non-CS complications (n = 9 patients, 7.2 %) included a pneumothorax (n = 1, 0.8 %), hematoma (n = 2, 1.6 %), subclavian vein thrombosis (n = 3, x%), and blood transfusion (n = 5, 4.0 %). A longer duration since implantation and larger lead diameter were associated with complex versus simple removal (p < .0001 and p = .0009 respectively). Percutaneous CS lead removal is successful by simple traction alone in the vast majority of cases. CS leads in place greater than 4 years, however, often require complex extraction. Specific extraction techniques can be implemented when simple traction is unsuccessful without an appreciable increase in complications.

Large, single-center experience in transvenous coronary sinus lead extraction: procedural outcomes and predictors for mechanical dilatation

BACKGROUND

The aim of this study was to evaluate procedural outcomes of coronary sinus (CS) lead extraction, focusing on predictors and need for mechanical dilatation (MD) in the event that manual traction (MT) is ineffective.

METHODS

The study assessed results in 145 consecutive patients (age 69 ± 10 years; 121 men)--a total of 147 CS pacing leads--who underwent transvenous CS lead removal between January 2000 and March 2010.

RESULTS

All leads but one (99%) (implantation time 29 ± 25 months) were successfully removed. MT was effective in 103 (70%), and MD was necessary in the remaining 44 (30%) procedures. In multivariate analyses, unipolar design (odds ratio [OR] 3.22, 95% confidence interval [CI] 1.43-7.7; P = 0.005) and noninfective indication (OR 4.8, 95% CI 1.8-13, P = 0.002) were independent predictors for MD (P < 0.0001), with a predictive trend for prior cardiac surgery (OR 2.2, 95% CI 0.98-5.26; P = 0.06). Five (3.4%) complex procedures required a transfemoral vein approach (TFA) or repeat procedure. No deaths occurred, and there was one major complication (0.7%), cardiac tamponade, after MT. No complication predictors were identified.

CONCLUSIONS

CS leads were safely and effectively removed in nearly all patients, and 70% were removed with MT alone; 30% required MD. Preoperative predictors suggesting the need for MD or TFA were noninfective indication and unipolar lead design. Complications were rare, and there was no predictable pattern among MT or MD removal techniques.

[Technical innovations and limitation in cardiac electrotherapy]

Coronary sinus (CS) lead positioning is one of the main determinants of cardiac resynchronization therapy (CRT). The implantation of the CS lead is faced with several technical difficulties that may prevent the achievement of a stable position and good performance of the CS lead without phrenic nerve stimulation (PNS). New developments in catheter and lead technology to overcome these difficulties are presented.

Improved success rate of cardiac resynchronization therapy implant by employing an active fixation coronary sinus lead

AIMS

Cardiac resynchronization therapy (CRT) is the standard treatment for heart failure with severe reduced left ventricular (LV) function and wide QRS complex. Coronary sinus (CS) lead implantation is challenging and accompanied by substantial dislocation rates. We evaluated the usage of an active fixation LV lead (Attain Starfix, Medtronic, MN, USA) with deployable lobes in challenging lead positions.

METHODS AND RESULTS

Between September 2006 and August 2009, 678 CRT devices were implanted. In 82 patients (12%) (59 male, 70 +/- 10 years, 39 ICM, 41 DCM, 2 valvular CM, LVEF 28 +/- 9%, NYHA 3.0 +/- 0.4, QRS 169 +/- 29 ms), the Attain Starfix active fixation lead was used. The main reason was intra-operative dislodgement of one (n = 47) or two (n = 5) passive fixation leads during implantation or revision procedure (n = 30). Active fixation lead implantation was overall successful with 90% (n = 74). Anatomical peculiarity was mostly an optimal lead position in otherwise unstable proximal parts of the target vein or a circumscripted areal of optimal threshold without phrenic nerve stimulation. At median follow-up of 99 days the threshold remained stable (1.2 +/- 0.8 vs. 1.0 +/- 0.5 V at 0.5 ms). Revisions due to instability in ectatic vein (n = 1) after 12 months and extractions (n = 2) because of device perforation/infection after 6/15 months were performed without complication.

CONCLUSION

The Attain Starfix active fixation lead proved to be an important option in anatomically challenging, otherwise unstable positions often located in the proximal part of the target vein. Lead revisions or extractions as late as 15 months after implantation were feasible.

Cardiac device therapy 1: theory, technology and terminology

With advancing technology and ever-expanding indications for implantable cardiac pacing and defibrillation devices, this article reviews modern day practice in this field. This article focuses on topics pertinent not only to cardiologists but also to general physicians, medical trainees and allied medical specialties.

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.

What can happen during coronary sinus lead implantation: dislocation, perforation and other catastrophes

Cardiac resynchronization therapy (CRT) using coronary sinus (CS) leads is an established method for the therapy of congestive heart failure (CHF) in the case of asynchronous ventricular contractions. Successful therapy depends on the placement of left ventricular leads usually via the coronary sinus (CS), a technically more challenging procedure than regular pacemaker implantations. Without specific precautions CRT implantation can be the gateway to a time consuming nightmare. Therefore CS lead implantation methods, with a focus on complications, were reviewed according to the literature and own experience with approximately 500 procedures from 1999-2007.