Single-site ventricular pacing via the coronary sinus in patients with tricuspid valve disease

Pilot study to evaluate left-to-right ventricular offset in biventricular pacing-comparison of electrocardiographic imaging and ECG

INTRODUCTION

Biventricular pacing (BiVp) improves outcomes in systolic heart failure patients with electrical dyssynchrony. BiVp is delivered from epicardial left ventricular (LV) and endocardial right ventricular (RV) electrodes. Acute electrical activation changes with different LV-RV stimulation offsets can help guide individually optimized BiVp programming. We sought to study the BiVp ventricular activation with different LV-RV offsets and compare with 12-lead ECG.

METHODS

In five patients with BiVp (63 ± 17-year-old, 80% male, LV ejection fraction 27 ± 6%), we evaluated acute ventricular epicardial activation, varying LV-RV offsets in 20 ms increments from -40 to 80 ms, using electrocardiographic imaging (ECGI) to obtain absolute ventricular electrical uncoupling (VEUabs, absolute difference in average LV and average RV activation time) and total activation time (TAT). For each patient, we calculated the correlation between ECGI and corresponding ECG (3D-QRS-area and QRS duration) with different LV-RV offsets.

RESULTS

The LV-RV offset to attain minimum VEUabs in individual patients ranged 20-60 ms. In all patients, a larger LV-RV offset was required to achieve minimum VEUabs (36 ± 17 ms) or 3D-QRS-area (40 ± 14 ms) than that for minimum TAT (-4 ± 9 ms) or QRS duration (-8 ± 11 ms). In individual patients, 3D-QRS-area correlated with VEUabs (r 0.65 ± 0.24) and QRS duration correlated with TAT (r 0.95 ± 0.02). Minimum VEUabs and minimum 3D-QRS-area were obtained by LV-RV offset within 20 ms of each other in all five patients.

CONCLUSIONS

LV-RV electrical uncoupling, as assessed by ECGI, can be minimized by optimizing LV-RV stimulation offset. 3D-QRS-area is a surrogate to identify LV-RV offset that minimizes LV-RV uncoupling.

Tricuspid regurgitation and infective endocarditis as a cause of lead dislodgement in left bundle branch area pacing

BACKGROUND

According to the current literature, there is no difference between left bundle brunch area pacing (LBBAP) and right ventricular apical pacing in terms of lead dislodgement and capture threshold elevation. However, there are no large-scale studies reporting the data about long-term lead stability in patients with severe tricuspid regurgitation.

METHODS AND RESULTS

We present a case of lead dislodgement with possible infective endocarditis six months after implantation in a patient with severe tricuspid regurgitation who underwent LBBAP.

CONCLUSIONS

We concluded that severe preoperative tricuspid regurgitation may cause lead dislodgement, and infective endocarditis may be a facilitator or main reason of lead dislodgement in cases of LBBAP.

Tricuspid valve disease and cardiac implantable electronic devices

The role of cardiac implantable electronic device (CIED)-related tricuspid regurgitation (TR) is increasingly recognized as an independent clinical entity. Hence, interventional TR treatment options continuously evolve, surgical risk assessment and peri-operative care improve the management of CIED-related TR, and the role of lead extraction is of high interest. Furthermore, novel surgical and interventional tricuspid valve treatment options are increasingly applied to patients suffering from TR associated with or related to CIEDs. This multidisciplinary review article developed with electrophysiologists, interventional cardiologists, imaging specialists, and cardiac surgeons aims to give an overview of the mechanisms of disease, diagnostics, and proposes treatment algorithms of patients suffering from TR associated with CIED lead(s) or leadless pacemakers.

Long-Term Atrioventricular Block Following Valve Surgery: Electrocardiographic and Surgical Predictors

BACKGROUND

Bradyarrhythmia requiring pacemaker implantation among patients undergoing valve surgery may occur even after several years, with unclear predictors. Our aim was to investigate the incidence of pacemaker implantation at different follow-up times and identify associated predictors.

METHODS

We conducted a retrospective study evaluating 1046 consecutive patients who underwent valve surgery at the Cardiac Surgery Division of Bologna University Hospital from 2005 to 2010.

RESULTS

During 10 ± 4 years of follow-up, 11.4% of these patients required pacemaker implantation. Interventions on both atrioventricular valves independently predicted long-term pacemaker implantation (SHR 2.1, 95% CI 1.2-3.8, p = 0.014). Preoperative atrioventricular conduction disease strongly predicted long-term atrioventricular block, with right bundle branch block as the major predictor (SHR 7.0, 95% CI 3.9-12.4, p < 0.001), followed by left bundle branch block (SHR 4.9, 95% CI 2.4-10.1, p < 0.001), and left anterior fascicular block (SHR 3.9, 95% CI 1.8-8.3, p < 0.001).

CONCLUSION

Patients undergoing valvular surgery have a continuing risk of atrioventricular block late after surgery until the 12-month follow-up, which was clearly superior to the rate of atrioventricular block observed at long-term. Pre-operative atrioventricular conduction disease and combined surgery on both atrioventricular valves are strong predictors of atrioventricular block requiring pacemaker implantation.

Lead management in patients undergoing percutaneous tricuspid valve replacement or repair: a 'heart team' approach

Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous trans-catheter tricuspid valve (TV) replacement and tricuspid trans-catheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a trans-venous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of 'jailing' a CIED lead at the time of a percutaneous TV intervention (lead fracture and risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this 'state-of-the-art' review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads, and advocate for including a lead management specialist as a member of the 'heart team' when making treatment decisions in patients TR and CIED leads.

Trans-oesophageal echocardiography-guided implantation of a cardiac resynchronization therapy pacemaker and successful ablation of the atrioventricular node after TriClip: case report

Background

Edge-to-edge intervention is the most common trans-catheter procedure performed for isolated severe tricuspid regurgitation in high-surgical-risk patients. However, it creates an obstacle for future right ventricular (RV) procedures such as implantation of cardiac implantable electronic devices (CIEDs). Reports of the management of CIED implantation after tricuspid edge-to-edge therapy are scarce.

Case summary

A 76-year-old woman suffered from severe tricuspid regurgitation with New York Heart Association three symptoms despite optimal medical therapy. After a thorough evaluation, the heart team recommended the TriClip procedure as the treatment of choice. However, 12 months after a successful TriClip procedure, rapid atrial fibrillation needed to be addressed with CIED implantation and atrioventricular (AV) node ablation. Pre-procedural planning included the intended posterior location of the CIED to avoid interference with the implanted clip and future AV node ablation. With an additional left ventricular lead positioned anteriorly to the RV lead, the posterior position of the RV lead was secured. Under peri-procedural trans-oesophageal echocardiography (TEE), the planned procedures were performed successfully.

Discussion

A blind manoeuvring of the RV lead may damage the edge-to-edge tricuspid device. In addition, friction due to an overly close contract between the RV lead and the edge-to-edge device may damage the RV lead. A successful and safe CIED implantation and atrioventricular node ablation can be performed after tricuspid edge-to-edge therapy with careful planning and its precise execution under TEE surveillance.

Cardiac pacing and lead devices management: 25 years of research at EP Europace journal

AIMS

Cardiac pacing represents a key element in the field of electrophysiology and the treatment of conduction diseases. Since the first issue published in 1999, EP Europace has significantly contributed to the development and dissemination of the research in this area.

METHODS

In the last 25 years, there has been a continuous improvement of technologies and a great expansion of clinical indications making the field of cardiac pacing a fertile ground for research still today. Pacemaker technology has rapidly evolved, from the first external devices with limited longevity, passing through conventional transvenous pacemakers to leadless devices. Constant innovations in pacemaker size, longevity, pacing mode, algorithms, and remote monitoring highlight that the fascinating and exciting journey of cardiac pacing is not over yet.

CONCLUSION

The aim of the present review is to provide the current 'state of the art' on cardiac pacing highlighting the most important contributions from the Journal in the field.

Cardiac Implantable Electronic Devices in Ebstein Anomaly: Management and Outcomes

BACKGROUND

Optimal management of cardiac implantable electronic devices (CIEDs) in patients with Ebstein anomaly during tricuspid valve (TV) surgery is unknown. Thus, we aimed to characterize CIED management/outcomes in patients with Ebstein anomaly undergoing TV surgery.

METHODS

Patients at the Mayo Clinic from 1987 to 2020 with Ebstein anomaly and CIED procedure were reviewed for procedural details, complications, echocardiogram, and lead parameters. Five-year cumulative incidence of CIED complications were estimated using the Kaplan-Meier method.

RESULTS

Ninety-three patients were included; 51 were female, and mean age was 40.7±17.5 years. A new CIED was implanted in 45 patients at the time of TV surgery with the majority receiving an epicardial (n=37) CIED. Among 34 patients who had preexisting CIED (11 epicardial, 23 transvenous) at time of TV surgery, 20 had a transvenous right ventricular lead managed by externalizing the lead to the TV (n=15) or extracting the transvenous lead with epicardial lead implantation (n=5). Fourteen patients underwent CIED implantation (4 epicardial, 10 transvenous) without concurrent surgery. Placement of lead across the TV was avoided in 85% of patients. The 5-year cumulative incidence of CIED complications was 24% with no significant difference between epicardial and transvenous CIEDs (26% versus 23%, P=0.96). Performance of lead parameters was similar in epicardial and transvenous leads during median (interquartile range) follow-up of 44.5 (61.1) months.

CONCLUSIONS

In patients with Ebstein anomaly undergoing TV surgery, the use of epicardial leads and externalization of transvenous leads to the TV can avoid lead placement across the valve leaflets. Lead performance and CIED complications was similar between epicardial and transvenous CIEDs.

Performance of pacemaker leads in alternative lead positions after tricuspid valve replacement

BACKGROUND

Bradycardic arrhythmias requiring pacemaker (PM) implantation are still common in patients in need of tricuspid valve replacement (TVR). Leaving an existing PM lead in an extravalvular position may represent a helpful alternative in special situations like the implantation of a mechanical TV. This study aimed to examine the short- to mid-term outcome of paravalvular leads concerning lead survival and prosthesis dysfunction in patients after TVR.

METHODS

A retrospective case-control study of patients with TVR and ventricular pacing was conducted. Patients from the database of the Leipzig Heart Center were included. Data of the paravalvular lead group (PVG) and coronary sinus lead group (CSG) were compared to a control group with conventional transvalvular leads (TVG).

RESULTS

Eighty patients with TVR and cardiac PM (TVG [n = 13], PVG [n = 40], and CSG [n = 27]) were included. The mean follow-up was 2.8 years. The rate of lead revisions (TVG 15.4%, PVG 2.5%, and CSG 7.5%) was lower in PVG but without significance (P = .286). The CSG demonstrated significantly higher pacing thresholds (1.4 V/0.8 ms) than TVG (0.5 V/0.4 ms), P = .004. However, the deterioration of threshold amplitudes during follow-up was similar in CSG (7.4%) and PVG (7.5%) compared with controls (7.7%). Function of TV prosthesis regarding development of stenosis or regurgitation showed a similarity between the groups (regurgitation PVG P = .692, CSG P = 1; stenosis PVG P = .586, CSG P = 0.69).

CONCLUSION

Paravalvular positioning of PM leads seems to represent a reasonable alternative to the conventional transvalvular lead positioning concerning the lead and Tricuspid Valve prosthesis's function and durability in selected patients.

Utility of a Leadless Pacemaker as a Backup to Left Ventricle-only Pacing in a Patient with Prior Device-related Severe Tricuspid Regurgitation

The contribution of endocardial cardiac device leads to severe tricuspid regurgitation (TR) has become increasingly recognized. Current strategies for treating cardiac device lead–related TR have limitations. We present a case of a pacemaker-dependent patient with severe TR as a complication of multiple cardiac device leads who underwent laser lead extraction, which was followed by implantation of a dual-chamber pacemaker with a coronary sinus lead for left ventricular pacing and a leadless transcatheter pacemaker for backup right ventricular (RV) pacing. This report represents one of the first cases of a leadless pacemaker implanted for RV backup pacing, highlighting the possibility of future biventricular pacing therapy (with a leadless pacemaker in VVT mode) without endocardial leads crossing the tricuspid valve.

Left ventricular pacing in patients with preexisting tricuspid valve disease

BACKGROUND

Conventional right ventricular (RV) pacing is increasingly recognised to cause tricuspid valve (TV) injury or dysfunction, in part due to the need to pass the lead through the valve. This may be especially problematic in patients with preexisting TV disease or prior TV surgery. An alternative in this situation is to implant a left ventricular (LV) lead instead of ventricular pacing.

METHODS

We performed a single-center retrospective analysis of 26 patients with tricuspid valve surgery/disease who received a LV pacing lead in the coronary veins to avoid crossing the tricuspid valve, with or without a right atrial lead. A matched control population was obtained from patients receiving conventional right ventricular pacing and outcomes were compared. Main outcomes of interest were lead stability, electrical lead parameters and change in echocardiographic parameters such as left ventricular ejection fraction (LVEF) during long-term follow-up.

RESULTS

Successful left ventricular pacing was established in 25 out of the 26 cases with one case converted to a RV lead due to lead dislodgement. During the 2.96 ± 1.0 year follow-up, 24 of 25 (96.0%) leads were functional with stable pacing and sensing parameters, and 1 of 25 (4.0%) was extracted for due to device infection following an episode of thrombophlebitis.

CONCLUSION

We conclude that in patients with existing tricuspid valve disease or surgery, ventricular pacing via the coronary veins is a feasible, safe, and reliable alternative to right ventricular pacing.

Single- and dual-site ventricular pacing entirely through the coronary sinus for patients with prior tricuspid valve surgery

PURPOSE

Transvenous right ventricular pacing has traditionally been avoided after surgical tricuspid valve repair or replacement because of possible valvular dysfunction. Epicardial pacing has been used but it requires surgical thoracotomy and has higher lead failure rates when compared to transvenous pacing. We evaluated the lead stability and clinical outcomes in patients with isolated coronary sinus (CS) lead due to relative contraindication to transvenous pacing from prior tricuspid valve (TV) surgery.

METHODS

We retrospectively examined a single-center cohort of 34 patients with TV disease and/or surgery who underwent permanent pacemaker implantation with a left ventricular CS lead as the only ventricular pacing lead (to avoid crossing the TV). The clinical outcome, echocardiographic data, and pacing thresholds were evaluated at follow-up.

RESULTS

We implanted 19 patients with a single-CS lead and 15 patients with dual-CS leads. The average left ventricular ejection fraction was 56 ± 13% prior to lead implantation and remained stable at 2-year follow-up. The tricuspid regurgitation remained mild at follow-up. The average lead pacing threshold was 1.2 ± 0.6 V × ms at implant and 1.1 ± 0.4 V × ms at 2-year follow-up (P = 0.39). For patients with dual-CS leads, the pacing threshold was 1.2 ± 0.7 V × ms at implant and 1.1 ± 0.5 V × ms at 2-year follow-up (P = 0.52).

CONCLUSIONS

The use of ventricular pacing entirely through the CS is an effective and minimally invasive method that provides stable pacing for patients with prior TV surgery in whom transvenous lead placement either is not possible or is relatively contraindicated.

A novel technique for lead sparing tricuspid valve replacement in the case of a transvenous ICD lead

Tricuspid valve (TV) surgery represents a complex consideration regarding lead management in patients with a transvenous ICD. The presented case shows favorable short-term results after lead sparing TV replacement, leaving an ICD lead in a paravalvular position. The described technique can be used in challenging cases of TV replacement.

Case presentation: implantation of cardiac resynchronization therapy pacemaker via the coronary sinus in a patient with triple valve replacement

Background

In patients with triple valve replacement developing third-degree atrioventricular block (AVB), the most appropriate approach for permanent pacemaker implantation remains questionable.

Case presentation

In this case presentation, we first described the approach of implantation of the cardiac resynchronization therapy pacemaker (CRT-P) via one bipolar pacing lead in middle cardiac vein (MCV) and one quadripolar pacing lead in anterior interventricular vein (AIV) in a patient developing complete AVB, who had been previously diagnosed with rheumatic valvular heart disease with triple valve replaced. After the CRT-P implantation, the two pacing leads in coronary sinus (CS) provided a dual-site ventricular pacing from the anterior septum and posterior septum, which resulted in a narrow QRS complex and an increased ventricular synchrony. During the long-term follow-up, no deterioration of heart function was documented and pacing parameters remained good.

Conclusion

In this patient developing complete AVB with triple valve replaced, our approach of CRT-P implantation provides an effective and reliable ventricular pacing, and is an alternative option when transvenous right ventricular pacing, transseptal left ventricular pacing and transpericardial epicardium pacing are not possible. Further prospective randomized trials are required to confirm the efficiency of our approach of dual-site ventricular pacing by CRT-P in this kind patients.