Effect of Percutaneous Interventions within the Coronary Sinus on the Success Rate of the Implantations of Resynchronization Pacemakers

Coronary venoplasty during cardiac resynchronization therapy device implantations: Acute results and clinical outcomes

BACKGROUND

Optimal left ventricular (LV) lead placement improves response to cardiac resynchronization therapy (CRT) but can be hindered by unfavorable venous anatomy. Interventional procedures in the coronary veins have been described with promising short-term outcomes.

OBJECTIVE

The purpose of this study was to establish the safety and efficacy of percutaneous coronary venoplasty (PCV) during CRT implantation and assess medium-term lead performances and clinical outcomes against matched controls not requiring PCV.

METHODS

Each consecutive PCV case was matched according to age, gender, and bundle branch morphology to 2 controls from a large prospective registry of CRT recipients. Demographics, procedural success, lead performance, and response to CRT were tracked using a comprehensive electronic medical records system.

RESULTS

Of 422 consecutive CRT recipients treated between 2012 to 2018, 29 patients (6.9%; mean age 65.7 ± 10.7 years; 7 female; 17 ischemic cardiomyopathy; 22 left bundle branch block) required PCV, which was successful in 21 cases (72%). Target veins measuring 1.1 ± 0.6 mm were dilated by noncompliant balloons with mean diameter 2.8 ± 0.5 mm. No complications occurred. Fluoroscopic and procedural durations were longer in the PCV group (P <.01) Over mean follow-up of 33.0 ± 25.0 months, no differences in lead performance, CRT response, or 2-year survival were observed compared to the control group.

CONCLUSION

PCV during CRT device implant is typically successful, safe and associated with long-term clinical outcomes comparable to patients who did not need PCV. This is an important technique to optimize LV lead placement and maximize CRT response.

Coronary venous angioplasty to facilitate transvenous left ventricular lead placement: A single-center 13-year experience

BACKGROUND

Barriers to successful left ventricular lead placement within the coronary venous anatomy may include focal stenoses, thromboses, phrenic nerve stimulation, vessel tortuosity, small vessel caliber, nonexcitable tissue, and valve presence. A large series describing the utilization of coronary venous angioplasty (CVAP) for relief of these issues is absent in the literature.

OBJECTIVE

We report our experience on all patients treated with CVAP in a single-center 13-year experience.

METHODS

Forty-seven patients with CVAP (64% male, mean age 67 ± 12 years) were treated by five different implanting physicians for approved cardiac resynchronization therapy indications. The reason for CVAP was categorized by obstacle (focal occlusion, valve presence, small caliber vessel) and location. The number, type, and size of balloon used, inflation characteristics, complications, and success of lead deployment crossing the point of intervention were all tabulated.

RESULTS

Seventy-seven percent of patients (36/47) had successful CVAP. The most common reason for intervention was a focal occlusion (24/47; 51%), followed by valve presence (13/47; 28%), and small vessel caliber (10/47; 21%). Focal occlusions were most successfully managed with CVAP (23/24; 96%), followed by small vessel caliber (7/10; 70%) and valve presence (6/13; 46%). The reason for failure was most commonly due to failure to relieve the obstruction (5/11; 45%), thrombosis (3/11; 27.3%), dissection (2/11; 18.2%), and inability to pass the balloon through the occlusion (1/11; 9.0%). There were no significant complications developed from CVAP utilization.

CONCLUSION

In a large analysis, CVAP can be safely and successfully performed in the majority of instances required.

Advanced left-ventricular lead placement techniques for cardiac resynchronization therapy

PURPOSE OF REVIEW

Due to complex venous anatomy and limitations in lead delivery tools and technology, the incidence of failed left-ventricular lead implants continues to be as high as 10%.

RECENT FINDINGS

A move towards an interventional approach to left-ventricular lead implantation has provided viable alternatives to surgical lead implantation. The use of telescoping sheaths, gooseneck snares and percutaneous balloon venoplasty may reduce procedural times by facilitating lead delivery despite challenging venous anatomy. In addition, recent advancements in left-ventricular lead technology now allow implanting physicians to overcome commonly encountered obstacles such as high thresholds and phrenic nerve stimulation, without having to move the lead from a stable position. For those with suboptimal or inaccessible coronary vein targets, a simplified transseptal endocardial implant approach has also been described.

SUMMARY

These recent advances in implant techniques and left-ventricular lead technology provide promising solutions to commonly encountered procedural obstacles in the implementation of resynchronization therapy. These alternative strategies will hopefully reduce the rate of failed implants and referrals for surgical epicardial leads.

CRT implantation: Lead stabilization using coronary sinus side branch stenting

Objective

We describe a method to stabilize CS lead position using stent implantation in a CS side branch to anchor the electrode to the wall of the vein, in cases of intraoperative or postoperative lead dislocation, unstable lead position and phrenic nerve stimulation (PNS).

Methods

403 patients were treated with stenting. After finding the desired lead position bare metal coronary stent was introduced via another guide wire, but in the same CS sheath. The stent was deposited 5–35 mm proximal to the tip of the electrode with a pressure of 6 to 14 atmospheres.

Results

Mechanical damage of the CS side branch or pericardial effusion was not observed. During follow-up (median 39, 23–48, max. 82 months) re-operation was necessary in only two patients because of high pacing threshold, while repositioning with ablation catheter was performed in 7 cases because of PNS. Impedance measurements did not suggest lead insulation failure. Transvenous extraction of stented CS leads was successful after 3, 18 and 49 months, while 4 leads were extracted easily during heart transplantation.

Conclusion

Stent implantation to stabilize CS lead position seems to be effective and safe for the prevention and treatment of CS lead dislocation in special cases.

Utility of a novel pacing guidewire in pre-implantation testing at different left ventricular sites in cardiac resynchronization therapy procedures

PURPOSE

This study aimed to evaluate the utility of a novel pacing guidewire in pre-implantation testing of different left ventricular (LV) sites during cardiac resynchronization therapy (CRT) procedures.

METHODS

Ten consecutive patients (8 male, mean age 65.8 ± 4.9) undergoing CRT procedures were studied. Pacing threshold and R-wave sensing measured by the guidewire and LV lead at different LV sites were compared.

RESULTS

Thirty sites (6 apical, 13 middle, and 11 basal; 15 lateral and 15 anterior) were tested. There was significant correlation between pacing threshold (r = 0.878, p < 0.0001), and R-wave sensing (r = 0.896, p < 0.0001) obtained by guidewire and those obtained by LV lead. Separating into lateral and anterior sites, significant correlation was also found in pacing threshold (lateral r = 0.658, p = 0.008; anterior r = 0.886, p < 0.0001) and R-wave sensing (lateral r = 0.887, p < 0.0001; anterior 0.865, p < 0.0001). For basal and middle sites, significant correlation was found in pacing threshold (basal r = 0.890, p < 0.0001; middle r = 0.878, p < 0.0001), and R-wave sensing (basal r = 0.930, p < 0.0001; middle r = 0.823, p < 0.001). No and borderline correlation was found in pacing threshold (r = 0.548, p = 0.26) and R-wave sensing (r = 0.835, p = 0.039), respectively, for apical sites. Concordance rate for the presence of phrenic nerve stimulation at high pacing output was 87%.

CONCLUSION

The accuracy of the novel pacing guidewire in pre-implantation testing in CRT procedures is site-dependent. There was good correlation with LV lead in the measurement of pacing threshold and R-wave sensing at basal and middle sites, but not apical sites. Presence of phrenic nerve stimulation can be predicted by guidewire testing with high accuracy.

Coronary venous lead implantation after an evaluation by virtual histology intravascular ultrasound and stenting of a stenosis

We describe a patient who developed coronary vein (CV) stenosis shortly (<3 months) after an initial left ventricular (LV) lead implantation with significant fibrous tissue. The virtual histological intravascular ultrasound analysis was useful for characterizing the plaque component of the stenotic lesion and formulating the strategy. A summarized review of the CV angioplasty for LV lead implantations disclosed that CV stenosis was often found in patients who had a previous history of cardiac surgery or an LV lead implantation and that a stent implantation was required to deploy the LV lead in the targeted CV in some (9.3%) patients.

Balloon-facilitated delivery of a left ventricular pacing lead

While modern implant tools have contributed greatly to the success of cardiac resynchronization therapy, technical challenges remain. A common problem is the inability to advance left ventricular pacing leads into branch veins that are tortuous or arise at steep angles. In these cases, advancement of the lead causes it to buckle and prolapse into the coronary sinus or great cardiac vein. Lead prolapsed can be avoided by employing a balloon to temporarily obstruct the coronary sinus or great cardiac vein just upstream from the branch vein. The balloon redirects the force of advancement laterally into the branch vein, facilitating delivery.

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.

Goose neck snare for LV lead placement in difficult venous anatomy

Venous anatomy frequently impairs placement of the left ventricular (LV) lead. In some cases, the wire will not advance into the vein and in others wire position is lost as the lead is advanced. This article describes how a commonly available goose neck snare is used to gain access to the distal end of the wire as it re-enters the coronary sinus retrograde via collaterals through an adjacent vein. The snare is advanced into the coronary sinus through the same catheter as the wire. The snare opens perpendicular to the long axis of the coronary sinus due to which the wire must pass through the open loop, provided the diameter of the snare is approximately the same as the coronary sinus. Thus no time-consuming manipulation of the snare is required. With access to both ends of the wire the vein is approached either retrograde (over the distal end) or antegrade (over the proximal end) while the other end of the wire is secured by the operator. Gaining control of both ends of the wire with a snare is another example of adapting interventional techniques for the device implantation. Unlike venoplasty, the snare does not evoke credentialing concerns and can be easily implemented by most implanting physicians.

How to use balloons as anchors to facilitate cannulation of the coronary sinus left ventricular lead placement and to regain lost coronary sinus or target vein access

Coronary venous anatomy can make successful implantation of a cardiac resynchronization therapy device difficult or impossible. Venogram and coronary balloons can be used as anchors to facilitate initial coronary sinus (CS) cannulation and left ventricular lead placement and to recover lost CS and target vein access.

Implant venoplasty: dilation of subclavian and coronary veins to facilitate device implantation: indications, frequency, methods, and complications

Subclavian vein (SV) obstruction occurs in 13-35% of patients with prior leads, resulting in use of proximal venous access, the other vein, laser lead extraction, or surgery. Surgery is required for optimal left ventricle lead placement in 10-15% of cardiac resynchronization therapy candidates because of small or stenotic veins. Published data describe the safe and successful balloon dilation of both subclavian and coronary veins (CV); however, implant venoplasty is rarely performed because many implanting physicians are not familiar with the use of balloons. This article outlines how we use venoplasty to facilitate implantation in our laboratory. The indications, frequency, observed and potential complications that have evolved with our experience are also discussed.

Is coronary vein angioplasty necessary to provide cardiac resynchronization in selected patients? A case report

Cardiac resynchronization therapy (CRT) has become a recommended method for patients with congestive heart failure (CHF) and cardiac dyssynchrony. In some cases, CRT implantation procedure can be complicated because of anatomic and technical reasons. Some reports describe balloon angioplasty of stenotic heart veins as a method to achieve the target vessel. We present a case of a 58-year-old male with permanent atrial fibrillation and CHF who was referred for CRT. During the implantation of the pacemaker, the diaphragmatic obstacle in coronary sinus (CS) has been passed after many attempts using a balloon catheter with no inflation. The aim of the report is to discuss, in short, the real necessity of venous angioplasty in the CS bed during CRT implantation.