Cardiac resynchronization therapy (CRT) is a well-established therapy for heart failure, wide QRS (>150 ms), and especially, left bundle branch block. Today, there are recognized techniques for achieving left ventricular (LV) lead implantation. Here we present our technique for direct LV lead placement in a patient without available tributaries in the coronary sinus (CS).
The patient is a 78-year-old male with paroxysmal atrial fibrillation and high ventricular rate under oral anticoagulation, ischemic heart failure in advanced functional class, left bundle branch block, wide QRS, and in optimal medical therapy, who was indicated for a cardiac resynchronization therapy defibrillator (CRT-D). His first procedure was performed conventionally, with two leads on the right side (atrial and ventricular), but we were unable to proceed with LV lead placement due to a large CS without any tributaries (Figure 1). The procedure was postponed for a second attempt. After discussion, we offered the patient direct LV lead placement since he would be maintained in oral anticoagulation. The second procedure was performed with a combined approach. In the right groin, we obtained venous femoral access and passed a long guidewire until it reached the right atrium; in the upper approach, we passed the long sheath through the subclavian vein and inside of it a snare wire. The snare was advanced until it captured the long transseptal wire (Figure 2), and then was advanced through the transseptal sheath until it reached the area of the inferior vena cava. After performing the conventional transseptal puncture, the upper sheath was advanced through the created hole using the snare as a guide to place the long wire inside the left atrium (left pulmonary vein). After that, a long screw-in LV lead was implanted in the basolateral area (Figure 3). The patient was discharged on the second day without any complications.
Although CRT is widely performed, the overall rate of failure of LV lead implantation in studies commencing before 2005 was 5.4%, and from 2005 onward, it was 2.4%.1 This is due to several causes, including failure to cannulate the CS or the absence of any suitable vein.1 In this case, we had the option of Hisian pacing using another right ventricular lead in the His area, but chose direct LV lead placement. While there are many descriptions of this technique, and especially in patients under oral anticoagulation, it was proven to be as effective as CS lead implantation in order to improve heart failure.
We describe our approach to direct left ventricular lead implantation using a snare wire as a guide for the long upper sheath to easily overcome the transseptal hole when CS lead implantation is not possible.
- Gamble JHP, Herring N, Ginks M, et al. Procedural success of left ventricular lead placement for cardiac resynchronization therapy: a meta-analysis. JACC: Clin EP. 2016;2(1)69-77.