The acute hemodynamic response to LV pacing within individual branches of the coronary sinus using a quadripolar lead

Background: It is not clear whether there is a large difference in acute hemodynamic response (AHR) to left ventricle (LV) pacing in different regions of the same coronary sinus (CS) vein. Using the four electrodes available on a Quartet LV lead, we evaluated the AHR to pacing within individual branches of the CS. Methods: An acute hemodynamic study was attempted in 20 patients. In each patient, we assessed AHR in a number of CS veins and along a significant proportion of each CS branch using three different bipolar configurations. We compared the AHR achieved when pacing using each different vector and also the highest AHR achieved in any position within the same patient with the lowest achieved in that patient. Results : Sixty‐four different CS positions in 19 patients were successfully assessed. No significant difference in AHR was found overall between the three vectors tested. The mean percentage difference in AHR between the CS branch vectors with the lowest and highest dP/dt_max was +6.5 ± 5.4% (P < 0.001). A much larger difference of +16.9 ± 6.1% (P < 0.001) was seen when comparing the highest and lowest AHR achieved using any vector in any position within the same patient. Conclusion: A small difference in AHR is seen when pacing within the same branch of the CS compared to pacing in different branches in the same patient. This suggests that although the site of LV lead placement is important, the position within a CS branch is less important than choosing the right vein. (PACE 2012; 35:196–203)     

Achieving Permanent Left Ventricular Pacing—Options and Choice

Cardiac resynchronization therapy (CRT) requires permanent left ventricular (LV) pacing. Coronary sinus (CS) lead placement is the first line clinical approach but can be difficult or impossible; may suffer from a high LV pacing threshold, phrenic nerve stimulation, and dislodgement; and produces epicardial LV pacing, which is less physiological and hemodynamically effective and potentially more proarrhythmic than endocardial LV pacing. CS leads can usually be extracted with direct traction but may require use of extraction sheaths. Half of CS side branches previously used for lead placement may be unusable for the same purpose after successful lead extraction, and 30% of CS lead reimplantation attempts may fail due to exhaustion of side branches. Surgical epicardial LV lead placement is the more invasive second line approach, produces epicardial LV pacing, and has a lead failure rate of ≈15% in 5 years. Transseptal endocardial LV lead placement is the third line approach, can be difficult to achieve, but produces endocardial LV pacing. The major concern with transseptal endocardial LV leads is systemic thromboembolism, but the risk is unknown and oral anticoagulation is advised. Among the new CRT recipients in the United States and Western Europe between 2003 and 2007, 22,798 patients may require CS lead revisions, 9,119 patients may have no usable side branches for CS lead replacement, and 1,800 patients may require surgical epicardial LV lead revision in the next 5 years. The CRT community should actively explore and develop alternative approaches to LV pacing to meet this anticipated clinical demand.     

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. (PACE 2012; 35:641–647)     

A new endocardial "over-the-wire" or stylet-driven left ventricular lead: first clinical experience

Transvenous left ventricular (LV) leads are primarily inserted "over-the-wire" (OTW). However, a stylet-driven (SD) approach may be a helpful alternative. A new polyurethane-coated, unipolar LV lead can be placed either by a stylet or a guide wire, which can be inserted into the lead body from both ends. The multicenter OVID study evaluates the clinical performance of this new steroid- and nonsteroid eluting lead. The primary endpoint is the LV lead implant success rate after identification of the coronary sinus (CS). Secondary endpoints include complication rate, short- and long-term lead characteristics, overall procedure and LV lead placement duration, total fluoroscopy time, and lead handling characteristics ratings. To date, 96 patients with heart failure (68 +/- 9 years old, 76% men) are enrolled. The CS was identified in 95 patients and, in 85 (88.5%), the LV lead was successfully implanted. The final lead positioning was lateral in 41%, posterolateral in 35%, anterolateral in 18%, and great cardiac vein in 6% of patients. In 70%, the 85 successful implantations, both stylet-driven and guide-wire techniques were used, a stylet only was used in 22%, and a guide wire only in 8%. Mean overall duration of 85 successful procedures was 112 +/- 40 minutes, total fluoroscopy time 28 +/- 15 minutes, and the duration of LV lead placement was 35 +/- 29 minutes. During a 3-month follow-up, the loss of LV capture occurred in three and phrenic nerve stimulation in six patients. The mean long-term pacing threshold is 0.8 V/0.5 ms and pacing impedance is 550 Omega. The OVID data suggest that these new leads are safe and effective. The choice of both OTW and SD techniques during lead implantation offers greater procedural flexibility.     

A New Endocardial "Over-the-Wire" or Stylet-Driven Left Ventricular Lead:

Transvenous left ventricular (LV) leads are primarily inserted "over-the-wire" (OTW). However, a stylet-driven (SD) approach may be a helpful alternative. A new polyurethane-coated, unipolar LV lead can be placed either by a stylet or a guide wire, which can be inserted into the lead body from both ends. The multicenter OVID study evaluates the clinical performance of this new steroid- and nonsteroid eluting lead. The primary endpoint is the LV lead implant success rate after identification of the coronary sinus (CS). Secondary endpoints include complication rate, short- and long-term lead characteristics, overall procedure and LV lead placement duration, total fluoroscopy time, and lead handling characteristics ratings. To date, 96 patients with heart failure (68 ± 9 years old, 76% men) are enrolled. The CS was identified in 95 patients and, in 85 (88.5%), the LV lead was successfully implanted. The final lead positioning was lateral in 41%, posterolateral in 35%, anterolateral in 18%, and great cardiac vein in 6% of patients. In 70%, the 85 successful implantations, both stylet-driven and guide-wire techniques were used, a stylet only was used in 22%, and a guide wire only in 8%. Mean overall duration of 85 successful procedures was 112 ± 40 minutes, total fluoroscopy time 28 ± 15 minutes, and the duration of LV lead placement was 35 ± 29 minutes. During a 3-month follow-up, the loss of LV capture occurred in three and phrenic nerve stimulation in six patients. The mean long-term pacing threshold is 0.8 V/0.5 ms and pacing impedance is 550 Ω. The OVID data suggest that these new leads are safe and effective. The choice of both OTW and SD techniques during lead implantation offers greater procedural flexibility.     

A Modified Transvenous Single Mechanical Dilatation Technique to Remove a Chronically Implanted Active‐Fixation Coronary Sinus Pacing Lead

We described a 77‐year‐old patient, previously implanted with a dual‐chamber pacemaker later upgraded to a cardiac resynchronization therapy‐defibrillator (CRT‐D) device with an active‐fixation coronary sinus pacing lead, who underwent a transvenous mechanical extraction procedure for a device‐related systemic infection. All leads were removed successfully with a transvenous approach. With regard to the coronary sinus (CS) lead (Attain 4195 StarFix, Medtronic Inc., Minneapolis, MN, USA), manual traction was ineffective and extraction required long and challenging mechanical dilatation up to distal CS using either conventional sheaths or modified CS lead delivery. (PACE 2010; 34:e66–e69)     

Left ventricular pacing lead positioning in the target vein of the coronary sinus: description of a challenging case

The optimal left ventricular pacing location for cardiac resynchronization therapy should be individualized according to the site of maximal mechanical delay. However, the presence of vein stenosis or kinking in coronary sinus (CS) anatomy could hamper lead implantation in the target vessel. We describe the case of a patient with dilated cardiomyopathy and a dual-chamber pacemaker referred for upgrading to a biventricular device owing to New York Heart Association III heart failure symptoms. Tissue Doppler analysis before implantation showed that the area of maximum activation delay was located in the posterolateral region of the left ventricle. Insertion of the lead into a posterolateral vein of the CS by means of the standard over-the-wire approach was unsuccessful due to the presence of a stenosis at the ostium of the vein. Lead placement in an anterior vein of the CS was unsatisfactory owing to a poor local delay from QRS onset. After balloon vein angioplasty, the pacing lead passed through the stenotic tract at the ostium of the target vein and was successfully positioned in the posterolateral region. Three months after pacemaker implantation, echocardiography showed an important reduction in the indexes of both inter- and intraventricular asynchrony and a significant left ventricular reverse remodeling     

Post-mortem Changes After Lead Extraction From the Ovine Coronary Sinus and Great Cardiac Vein

We investigated in sheep, non-thoracotomy extraction of leads which had been chronically implanted in the right atrium (RA), coronary sinus/great cardiac vein (CS / GCV) and right ventricle (RV) for atrial implantable defibrillation. Clinical success of extraction as well as gross and histologic findings in the heart are reported. Six of nine sheep had successful extractions. The major complication was laceration of the wall of the great coronary vein with hemorrhage into the pericardial space and cardiac tamponade. Tissue damage included several reversible changes: intra-tissue hemorrhage, thrombosis in the veins, and some necrosis of fat, vascular wall and myocardium. Myocyte necrosis was estimated as 0.03 to 0.3 grams of tissue. Osseous and cartilaginous metaplasia was more common around the RA lead than the CS/GCV lead. In cases where the lead must be removed, removal from the venous insertion site using lead extraction equipment should only be attempted with surgical back-up for emergency thora-cotomy to control hemorrhage in the event of vessel laceration. Safer explantation of these leads from the vein entry site will require the development of new extraction procedures.     

Interventional approach to CRT in a patient with drainage of the superior vena cava into the coronary sinus

A persistent left superior vena cava markedly increases the size of the coronary sinus (CS), which can increase the difficulty of left ventricular (LV) lead placement in patients receiving cardiac resynchronization therapy (CRT). We present a case where the entire superior vena cava drains into the coronary sinus, creating a massive CS. We also describe an interventional approach to LV lead implantation utilizing a combination of delivery systems from different vendors.     

Coronary sinus lead extraction in the era of cardiac resynchronization therapy: single center experience

As the number of coronary sinus (CS) lead implantations for cardiac resynchronization therapy increases so will the need for extraction of these leads. The safety of extraction of leads from the branches of the CS has not been reported. We reviewed our database of patients undergoing pacemaker lead extraction from January 2002 through February 2004 at our institution. Of 149 patients referred for lead extraction, 14 (9%) had a biventricular device. The indications for lead extraction were infection, lead malfunction, and exit block. The duration of CS lead implants ranged between 2 and 43 months (mean 17 months). All 14 CS leads were removed successfully using nonsurgical lead extraction techniques. Three leads that were in place the longest (≥27 months) were removed via the femoral vein approach due to fibrous attachment of the CS lead body to the other pacemaker leads. The leads were structurally intact and without any significant fibrosis of their tips upon visual inspection. There were no major complications of CS laceration, hypotension, pericardial effusion, or excessive blood loss associated with any of the extraction procedures. CS leads were removed safely, successfully and with relative ease based on our experience in this small cohort of patients.     

Coronary Sinus Lead Extraction

TYERS, G.F.O., et al .: Coronary Sinus Lead Extraction. Complications are reported more frequently with the implantation of coronary sinus (CS) than other types of leads, and attempts to extract CS leads may also be associated with increased risks. The authors have performed nonthoracotomy lead extraction (LE) since 1981 and maintained a detailed database. By November 2001, 796 leads had been removed from 401 patients. We undertook review of our CS-LE experience to evaluate prevalence, safety, and efficacy. Of 14 patients referred for CS-LE, 7 were treated in the last year. In six the lead had been placed in the CS intentionally, and in eight inadvertently. One recent patient treated with biventricular pacing was septic and died before LE was undertaken. In nine men and four women (mean age 66 years) had one each CS lead and a total of 34 LEs (2.6/patient). Four CS leads had been in place for <6 months (mean 1.5 month), whereas nine had been in place for between 6 months and 27 years. Several LE methods were used, from simple traction to the use of intraluminal locking stylets and powered sheaths. Complete removal of all leads was achieved in all patients. CS-LE required a mean of 13 minutes, including 1.8 minutes of fluoroscopy. There were no serious complications during the procedures, and the mean hospital stay was 4 days. (PACE 2003; 26[Pt. II]:524–526)     

Cardiac resynchronization after left ventricular lead extraction: usefulness of angioplasty in coronary sinus stenosis

A 68-year-old man, 54 months after having been implanted with a biventricular device, underwent successful extraction of the malfunctioning left ventricular (LV) lead using mechanical dilation. During LV lead reimplantation, venography documented stenosis of the coronary sinus (CS). To overcome the obstacle, balloon angioplasty was performed and a LV lead was then inserted into a lateral tributary of the CS. The procedure was complicated by local infection and, after 2 months, removal of the entire unit became necessary. During controlateral device implantation, a second angioplasty was carried before insertion of the new LV lead because, in the meantime, restenosis had developed in the CS.     

Percutaneous lead and system extraction in patients with cardiac resynchronization therapy (CRT) devices and coronary sinus leads

Background: Cardiac resynchronization therapy (CRT) device and coronary sinus (CS) lead extraction is required due to the occurrence of system infection, malfunction, or upgrade. Published series of CS lead extraction are limited by small sample sizes. We present a 10‐year experience of CRT device and CS lead extraction. Methods: All lead extractions between 2000 and 2010 were entered into a computer database. From these, a cohort of 71 cases involving a CRT device or CS lead was analyzed for procedural method, success, and complications. Results: Sixty coronary sinus leads were extracted in 71 cases (median age 71 years; 90% male) by manual traction/locking stylets (n = 54) or using a laser sheath (n = 6). Procedural success was achieved in 98% of CS leads. A total of 143 non‐CS leads were extracted, with laser required in 46% of cases. The mean duration of lead implantation was 35.8 months (range 1–116 months) and 2.86 ± 1.07 leads were extracted per case. CRT extraction case load increased significantly over time. Minor complications occurred in four (5.6%) cases and major complications in one (1.4%) case. There were no intraprocedural deaths, but two deaths occurred within 30 days of extraction. Conclusions: Our 10‐year experience confirms that percutaneous removal of CS leads can be achieved with high procedural success. Our recorded complication rates are no higher than those of non‐CS lead extraction series, and should be taken in the context of the frail nature of CRT patients. Ongoing audit of procedure success and complications will be required to further guide best practice in CS lead extraction. (PACE 2011; 34:1209–1216)     

Permanent nonselective His bundle pacing in an adult with L‐transposition of the great arteries and complete AV block

We report the placement of a permanent transvenous nonselective His bundle pacing lead in conjunction with a transvenous pacemaker/implantable cardioverter‐defibrillator in an adult with Levo‐Transposition of the Great Arteries (L‐TGA) and a stenotic coronary sinus (CS) ostium, which would not accommodate a transvenous left ventricular (LV) pacing lead. Nonselective His bundle pacing provided a nearly identical ventricular activation pattern in this previously unpaced patient. Many L‐TGA patients will have an eventual need for permanent pacing and, given the challenges of CS cannulation, His bundle pacing may represent a preferred modality rather than pure morphologic LV pacing or surgical systemic ventricular lead placement to achieve optimal electrical synchrony.     

Retrograde Buddy Wire Technique for Coronary Sinus Lead Placement—An Approach to Overcome Coronary Vein Angulation

Implantation of a left ventricular pacing lead via the coronary sinus to deliver cardiac resynchronization therapy has become standard therapy for patients with New York Heart Association (NYHA) Class III or IV heart failure and significant intraventricular conduction delay. Biventricular pacing has been shown to provide both symptomatic and mortality benefit in appropriately selected patients. There is significant variability in the anatomy of the coronary sinus and the epicardial coronary venous system. Although a suitable candidate vein may be identified during coronary venography, efforts toward successful guidewire placement or lead placement may be hampered by anatomic obstacles. In this case report, we provide a solution to overcome severe tortuosity encountered at the vein—coronary sinus junction and angulation of the proximal vein. The use of a second coronary sinus sheath and a retrogradely placed guidewire may overcome this anatomic obstacle of vessel tortuosity, when placement by other means has proven unsuccessful. (PACE 2013; 36:e41–e44)     

Postmortem anatomy of the coronary sinus pacing lead

Biventricular pacing nowadays represents a recognized method of nonpharmacological treatment of severe congestive heart failure refractory to medication. A growing number of biventricular implants is likely to bring an increasing demand for the extraction of specially designed coronary sinus (CS) leads for left ventricular pacing. There is a lot of data regarding conventional pacing or defibrillation lead extractions, but only very limited experience with the CS lead extractions. We describe the pathological-anatomical findings of a woman who died after 26 months postimplantation due to refractory ventricular fibrillation with focus on the left ventricular pacing lead course and feasibility of extraction.     

Event-free survival following CRT with surgically implanted LV leads versus standard transvenous approach

Background: While surgical epicardial lead placement is performed in a subset of cardiac resynchronization therapy patients, data comparing survival following surgical versus transvenous lead placement are limited. We hypothesized that surgical procedures would be associated with increased mortality risk. Methods: Long‐term event‐free survival was assessed for 480 consecutive patients undergoing surgical (48) or percutaneous (432) left ventricle (LV) lead placement at our institution from January 2000 to September 2008. Results: Baseline clinical and demographic characteristics were similar between groups. While there was no statistically significant difference in overall event‐free survival (P = 0.13), when analysis was restricted to surgical patients with isolated surgical lead placement (n = 28), event‐free survival was significantly lower in surgical patients (P = 0.015). There appeared to be an early risk (first approximately 3 months postimplantation) with surgical lead placement, primarily in LV lead‐only patients. Event rates were significantly higher in LV lead‐only surgical patients than in transvenous patients in the first 3 months (P = 0.006). In proportional hazards analysis comparing isolated surgical LV lead placement to transvenous lead placement, adjusted hazard ratios were 1.8 ([1.1,2.7] P = 0.02) and 1.3 ([1.0,1.7] P = 0.07) for the first 3 months and for the full duration of follow‐up, respectively. Conclusions: Isolated surgical LV lead placement appears to carry a small but significant upfront mortality cost, with risk extending beyond the immediate postoperative period. Long‐term survival is similar, suggesting those surviving beyond this period of early risk derive the same benefit as coronary sinus lead recipients. Further work is needed to identify risk factors associated with early mortality following surgical lead placement. (PACE 2011; 34:490–500)     

Long-term Stability of Endocardial Left Ventricular Pacing Leads Placed via the Coronary Sinus

Background: Left ventricular endocardial pacing leads placed via the coronary sinus (CS) are increasingly implanted to achieve cardiac resynchronization therapy (CRT); however, the long-term stability of these leads is unknown. We sought to determine the implant success and long-term stability of CS leads in our single center experience.
Methods: All consecutive patients who underwent CRT via implantation of the CS lead between January 1999 and December 2005 were included. Pacing thresholds at implant and during long-term follow-up were reviewed and the rate of acute (within 24 hours of implant) and chronic (>24 hours) lead failure was determined.
Results: A total of 512 patients (mean age 68 ± 12 years; 409 [80%] male) underwent CRT device implantation and were included. The CS lead implantation was successful on the initial implantation in 487 patients (95%) and subsequently successful in six patients (24%) in whom initial attempts were unsuccessful. Acute lead failure occurred in 25 patients (5.1%) and was most commonly due to persistent extra-cardiac stimulation. The rate of chronic lead failure was 4% in the first year and remained stable during long-term follow-up. The CS lead pacing thresholds remained stable with only minimal increase (1.42 ± 0.85 V/0.42 ± 0.25 ms vs 1.51 ± 1.05 V/0.47 ± 0.29 ms; P = 0.04).
Conclusions: Placement of a left ventricular pacing lead via the CS is feasible and safe in the vast majority of patients. Once placed, the CS leads remain stable with excellent pacing thresholds over the longer term.     

Beyond coronary sinus angiography: the value of coronary arteriography and identification of the pericardiophrenic vein during left ventricular lead placement

OBJECTIVE: The purpose of this study was to define the role coronary arteriography (venous phase) for improving the success of left ventricular (LV) lead implantation and to define the value of identifying the pericardiophrenic vein for optimal LV lead placement in biventricular (bi-v) device implantation. METHODS: Seventy-seven patients underwent bi-v device implantation between July 2002 and October 2003. If the coronary sinus (CS) could not be accessed, then left coronary arteriography was performed during the same procedure. CS access was guided by venous phase images of the coronary arteriogram. The pericardiophrenic vein was identified by selective cannulation or direct visualization. Patients with Cr > 1.5 had gadolinium used as the contrast agent. RESULTS: Seventy-five successful implants were performed (97%). In seven patients (9%) repeated attempts at retrograde cannulation of the CS failed (attempt time 130 +/- 20 minute, mean +/- SD). In these patients, coronary arteriography helped define the location of the CS, which was subsequently successfully cannulated. In six patients the pericardiophrenic vein was identified either during occlusion venography of the CS (postthoracotomy, veno-venous collaterals, n = 2) or during selective cannulation of the pericardiophrenic vein (using a DAIG Csl catheter, n = 4). The vein was directly visualized in three patients who underwent surgical LV lead implantation. LV leads in all these cases were implanted in areas not overlying the preidentified pericardiophrenic vein. During follow-up, none of these patients had evidence of phrenic nerve stimulation. CONCLUSIONS: Intraoperative left coronary arteriography increases the success of CS cannulation. Identification of the pericardiophrenic vein is a useful method to avoid phrenic nerve stimulation.     

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. (PACE 2013; 36:e31–e34)