Implantation of BIV ICD with Near Zero Contrast Use in Patients with Advanced Renal Insufficiency Using Three Dimensional Electro-anatomical Mapping.

Abstract

Biventricular (BIV) ICD implantations are traditionally performed using contrast and fluoroscopic guidance. Contrast use in patient with advanced renal disease can cause deterioration of renal function and even lead to dialysis. To evaluate the feasibility of utilizing 3 D mapping technique in reducing or eliminating contrast use in patient with advanced renal disease. The study consisted of 30 consecutive adult patients, in which BIV implantation was accomplished in advanced renal disease (stage III and IV GFR 15 to 59) by electroanatomical 3D mapping (EAM).Acute procedural success was 96% and only one patient LV lead implantation was unsuccessful due to unsuitable anatomy.47 % of patients had BIV ICD implantation with zero contrast. Average contrast exposure for the group was 4.3 ml only. Average ratio of contrast use to GFR (glomerular filtration rate) was only 0.1. Improved mean GFR was observed from 42 to 50 post procedure (P value<0.01), and continued to improve to 48 at 3 and 6 month (P value<0.01) and improvement decreased to 45 and 44 beyond 6 month and 1 year (P value NS). There was no single case of contrast induced acute renal insufficiency (CI-ARI) due to minimal use of contrast.69 % of the patients experienced an improvement in their functional class. A decrease in QRS duration was seen from 159 to 136 milliseconds (86% of patients had improved QRS duration); P value = <0.001. The average pre procedure ejection fraction (EF) for the group was 23%. The average EF post procedure for the group was 35%; P values = <0.001 (72% of patient had EF improvement).93% of patient had either EF and/or GFR improvement suggesting substantial clinical benefit from the procedure.There was no minor or major complications. Implantation of BiV ICD using EAM with near zero contrast is feasible, safe and effective in patients with moderate to severe renal insufficiency. There is an added renal protection and benefit from procedure in this group of patients.