A streamlined technique of trans-septal endocardial left ventricular lead placement

Abstract

Trans-septal endocardial left ventricular (LV) lead placement has been used for LV pacing in a small number of patients, partially due to difficulty in achieving the aim in practice. Based on analysis of the pre-existent techniques and exploitation of the latest developments in lead technologies, a new technique for trans-septal endocardial LV lead placement was devised. The inter-atrial septum (IAS) was punctured and a guide wire placed in the left atrium (LA) from the right femoral vein. A SelectSite C304-S59 catheter (Medtronic) was introduced from an upper body vein and deflected so that its tip approached the IAS puncture as marked by the guide wire already in the LA. The dilator supplied with the SelectSite catheter was used to engage the IAS puncture and pass a guide wire into the LA. The dilator was advanced over the guide wire, and then the catheter over the dilator, into the LA. The catheter was undeflected and torqued clockwise to prolapse the catheter-dilator-guide wire assembly into the LV cavity. The dilator-guide wire assembly was exchanged for a SelectSecure 3830-69 cm lead, which was deployed on the LV endocardial surface. The catheter was withdrawn entirely into the right atrium before it was slit. The new technique was successfully implemented in a patient who required cardiac resynchronization therapy. The new technique appears more streamlined and efficient than the pre-existent techniques and may make trans-septal endocardial LV lead placement a more clinically utilized alternative to coronary sinus and surgical epicardial LV lead placement.