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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 9
| Issue : 1 | Page : 54-59 |
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Cardiac resynchronization therapy left ventricular lead through middle cardiac vein: A feasibility study with short-term follow-up
Arindam Pande, Dilip Kumar, Sanjeev S Mukherjee, Soumya Patra, Rana Rathore Roy, Somnath Dey, Rabin Chakraborty
Department of Cardiology, Medica Superspecialty Hospital, Kolkata, West Bengal, India
| Date of Submission | 09-Dec-2020 |
| Date of Decision | 07-Feb-2021 |
| Date of Acceptance | 25-Feb-2021 |
| Date of Web Publication | 30-Mar-2021 |
Correspondence Address:
Dr. Arindam Pande
BE 105, Saltlake City, Sector 1, Kolkata - 700 064, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/heartindia.heartindia_56_20
Purpose: The benefits of cardiac resynchronization therapy (CRT) depend on multiple factors including patient selection and left ventricular (LV) lead position in the coronary sinus. The ideal position for stimulation is the posterolateral region of the left ventricle, since this is the site where maximum contractile delay is seen. But this ideal site of LV lead placement is not possible in many patients due to anatomical limitations. Our study evaluated the feasibility of the middle cardiac vein (MCV) as an alternative target for LV lead placement with short-term outcomes result in a small cohort of patients.
Methods: This is a single-center experience over a span of 2 years where in patients with anatomical limitations, we positioned our LV leads through MCV. In this period, we had implanted a total of 76 CRTs in our institution, out of which 6 cases we used MCV. We utilized collateral circulation to reach as close possible to the lateral surface of the left ventricle. Right ventricular (RV) leads were positioned to either outflow tract or upper septum to enhance the electrical gap in between two ventricular leads.
Results: We achieved satisfactory periprocedural end results in all the cases as evident by appropriate threshold/impedances of all the leads, lack of diaphragmatic stimulation, etc. There were no procedural complications. Optimum short- and midterm improvement of symptomatic class and LV ejection fraction was observed. None of the patients had any lead dislodgement, abnormal change in lead threshold parameters, or need for hospitalizations for heart failure in follow-ups.
Conclusion: We conclude that when usual posterolateral or lateral target veins cannot be accessed for LV lead placement, as an alternative approach utilizing MCV collateral circulation to reach as close possible to the lateral surface may be considered in CRT. RV leads to be positioned at the outflow tract or upper septum in those cases.
Keywords: Anatomical limitation, bi-ventricular pacing, cardiac resynchronization therapy, middle cardiac vein, septal pacing
How to cite this article:
Pande A, Kumar D, Mukherjee SS, Patra S, Roy RR, Dey S, Chakraborty R. Cardiac resynchronization therapy left ventricular lead through middle cardiac vein: A feasibility study with short-term follow-up. Heart India 2021;9:54-9 |
How to cite this URL:
Pande A, Kumar D, Mukherjee SS, Patra S, Roy RR, Dey S, Chakraborty R. Cardiac resynchronization therapy left ventricular lead through middle cardiac vein: A feasibility study with short-term follow-up. Heart India [serial online] 2021 [cited 2021 Aug 1];9:54-9. Available from: https://www.heartindia.net/text.asp?2021/9/1/54/312494 |
| Introduction | |  |
Cardiac resynchronization therapy (CRT) is an important treatment option in patients with progressive heart failure. Ample scientific evidence is there in the literature to support the adequacy of this therapeutic option.[1] However, the benefits of CRT are dependent on multiple factors like patient selection and left ventricular (LV) lead position in the coronary sinus (CS). The classic indication is sinus rhythm with complete left bundle branch block (LBBB) on electrocardiography (ECG) with wide QRS duration and LV ejection fraction <35%. The ideal position for ventricular stimulation is the posterolateral region of the left ventricle, since this is the site where maximum contractile delay is supposed to be observed. This ideal site is not accessible in some cases due to multiple reasons.[2] Here, we are reporting our single-center experience of 6 cases over a span of 2 years where LV leads were positioned through the middle cardiac vein (MCV).
Case histories and procedure details
Clinical presentations and implantation procedure details of the cases are summarized in [Table 1]. In all our 6 cases, we could not access the usual posterolateral or lateral branches of CS for LV lead placement because of inadequate caliber, stenosis, sharp bends, or absence of target vein altogether. As surgical placement of epicardial LV leads involves higher risk and morbidities for these very sick patients, we implanted the LV leads through MCV as an alternative target. There are anecdotal reports of successful CRT using MCV to place LV leads. We utilized collateral circulation to reach as close possible to the lateral surface. In all the cases, LV lead positioning was guided by measurement of QLV (QLV is the electrical delay between Q wave of surface ECG and sensing from the LV lead) to reach the site of the latest electrical activation. Only LV lead positions with QLVs of >90 ms were accepted. Right ventricular (RV) leads were positioned to either outflow tract or upper septum to enhance the electrical gap in between two ventricular leads. In order to position RV lead on the septal aspect, we prepared the stylet with posterior 90° angulation near the tip and a generous primary curve at 5–6 cm proximal to the tip.[3] Hence, in the left anterior oblique fluoroscopic view, the septal lead points toward the spine. The final positions of atrial and ventricular leads are shown in [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]. Pre- and postimplantation ECGs of lead I and V1 of patients 1–6 are shown in [Figure 7]. We achieved satisfactory periprocedural end results in all the cases. There were no procedural complications. Optimum improvement of symptomatic class and LV ejection fraction was observed. None of the patients had any lead dislodgement, abnormal change in lead threshold parameters, or required hospitalizations for heart failure in follow-up. The overall response was satisfactory. [Table 2] summarizes the baseline parameters, short and midterm outcomes of the 6 cases which we performed over a span of 2 years. | Figure 1: Cardiac resynchronization therapy with left ventricular quadripolar lead at the middle cardiac vein, right ventricular lead at outflow tract, and right atrial lead at appendage in a 74-year-old diabetic female (Patient 1)
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 | Figure 2: Cardiac resynchronization therapy with left ventricular bipolar lead at the middle cardiac vein
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 | Figure 3: Cardiac resynchronization therapy with left ventricular quadripolar lead at the middle cardiac vein, right ventricular lead at outflow tract, and right atrial lead at appendage in a 62-year-old male with 2:1 heart block (Patient 3)
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 | Figure 4: Cardiac resynchronization therapy with left ventricular quadripolar lead at the middle cardiac vein, right ventricular lead at outflow tract, and right atrial lead at appendage in a 47-year-old hypertensive female with chronic kidney disease on maintenance hemodialysis (Patient 4)
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 | Figure 5: Cardiac resynchronization therapy with left ventricular quadripolar lead at the middle cardiac vein, right ventricular lead at outflow tract, and right atrial lead at appendage in a 68-year-old hypertensive diabetic female (Patient 5)
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 | Figure 6: Cardiac resynchronization therapy with left ventricular quadripolar lead at the middle cardiac vein, right ventricular lead at outflow tract, and right atrial lead at appendage in a 56-year-old hypertensive diabetic male with intermittent 2:1 heart block in Holter monitoring (Patient 6)
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 | Figure 7: Pre- and postcardiac resynchronization therapy implantation electrocardiography of lead I and V1 of patients 1–6
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 | Table 2: Comparison of baseline, 3-month, and 6-month follow-up parameters
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| Discussion | | |
Cardiac resynchronization is an effective therapy in patients with wide QRS with complete LBBB on ECG and LV ejection fraction <35%. There are multiple benefits including increased exercise time, decreased heart failure symptoms, improved quality of life, and reduced mortality. The extent of improvement depends on resynchronization of atrioventricular, interventricular, and intraventricular dyssynchrony. Appropriate placement of LV lead becomes a major determinant of the hemodynamic response.[4]
In some cases, transvenous CS LV leads' placement becomes challenging due to anatomical limitations. There may be some congenital problems like Thebesian or Vieussens valves. In other cases, it may be functional hindrances arising due to acute angle, small caliber size, excessive tortuosity, epicardial course, or stenosis of the target vein. Particularly in postcoronary artery bypass grafting cases, there may be further difficulty due to alteration of anatomical relations or venous occlusion.[5] Various modified techniques can aid in successful vein cannulation like the buddy wire, balloon angioplasty, and stenting of venous obstruction or using the collateral pathway.[6] Over the last few years, there has been a substantial improvement in the procedural techniques such as antidromic and orthodromic snare techniques, double wire techniques, using microcatheters, or telescopic sheaths in these difficult anatomical situations.[7] There has been also tremendous development in the lead designs as well.
Meticulous study and planning of venous branching pattern including collaterals in preimplantation work up[8],[9] can be very helpful in successful LV lead placement in difficult anatomies when the regular approach is unsuccessful. In our cases, multiple techniques for implantation of the LV lead to posterolateral/lateral veins were either not successful or those veins were inappropriate as target. However, we were able to achieve better lead position, stability, and pacing thresholds via the use of MCV. We utilized collateral circulation to reach as close possible to the lateral surface of LV to reach the site of the latest activation. RV leads were positioned to either outflow tract or upper septum to enhance the electrical gap in between two ventricular leads. We know that pacing from RV septum/outflow tract shifts the axis more inferiorly. The LV lead from MCV, slightly more basal, and the RV lead at the upper septum or outflow tract generates two opposing wavefronts which cancels each other and normalizes the QRS.[10] We hypothesize, this has caused substantial QRS narrowing that we observed in majority of our cases. There were no periprocedural, short or midterm complications of the procedure. Satisfactory improvements in symptomatic classes of the patient and LVEF in echocardiography were observed on follow-up visits. Interestingly, none of our patients had any further heart failure hospitalizations in the postprocedure period. There are few isolated reports of using MCV as target for LV lead placement.[11],[12] We present the current series to re-emphasize this approach with some procedural modifications to manage these difficult cases. At the present time, with the availability of modern algorithms, such as “Multipoint pacing,” “Adaptive CRT” (Medtronic), or “SYNC–AV” (ST. Jude Medical) has further improved the response of cardiac resynchronization. So in difficult anatomical situations, positioning LV lead in MCV can provide acceptable alternative of periprocedural success as well as short and midterm outcomes.
| Conclusion | | |
Preimplantation meticulous study and planning of venous branching pattern including collaterals can be very helpful in successful LV lead placement in difficult anatomies. However, when usual posterolateral or lateral target veins are not accessible, utilizing MCV collateral circulation to reach as close possible to the lateral surface of the left ventricle may be considered as an alternative before sending the patients for surgical LV lead implantation by thoracotomy. In our series of 6 cases, we achieved good short-term outcome in this technique. RV leads to be positioned at outflow tract or upper septum in those cases to enhance the electrical gap in between two ventricular leads. Our study is limited by small sample size and short follow-up period; however, it can be an important source of hypothesis generation and future research.
Acknowledgment
The authors would like to thank Mr. Arnab Dey, Senior Administrator and Technologist In-charge, Catheterization Laboratory, Department of Cardiology, Medica Superspecialty Hospital, Kolkata, India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Ethical approval
Ethical approval was obtained from the institutional ethical committee.
Authors' contributions
AP was involved in conceptualization, data collection, performing surgeries, manuscript writing and proof correction. DK was involved in conceptualization, data collection, performing surgeries. SSM was involved in conceptualization, data collection, manuscript writing and proof correction. SP, RRR and SD were involved in data collection and statistical analysis. RC was involved in conceptualization and manuscript writing.
| References | | |
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| 8. | de Voogt WG, Ruiter JH. Occlusion of the coronary sinus: A complication of resynchronisation therapy for severe heart failure. Europace 2006;8:456-8. |
| 9. | Soga Y, Ando K, Nobuyoshi M. Collateral approach for biventricular pacing of coronary sinus ostium obstruction. Pacing Clin Electrophysiol 2008;31:122-4. |
| 10. | van Stipdonk A, Wijers S, Meine M, Vernooy K. ECG patterns in cardiac resynchronization therapy. J Atr Fibrillation 2015;7:1214. |
| 11. | Bali HK, Chattree KK, Bali SK, Chauhan HK, Shukla CP. Collateral approach for LV lead implantation in a case with abnormal venous anatomy. Indian Heart J 2013;65:607-10. |
| 12. | Zheng C, Lin WQ, Lin YZ, Lian H, Liu ZR, Chen JH, et al. Case presentation: Implantation of cardiac resynchronization therapy pacemaker via the coronary sinus in a patient with triple valve replacement. BMC Cardiovasc Disord 2018;18:37. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]
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