Implantation: tips and tricks ? the cardiologist's view

Abstract

Since the development of the first epicardial left ventricular pacemaker leads, the design of transvenous coronary leads has progressed tremendously. Due to the safe access to the target region independent of previous surgical interventions and a low morbidity, the transvenous placement has become the method of choice. Catheterization of the coronary sinus is required to place the coronary venous lead. The most difficult anatomical situation is the pipe-shaped coronary sinus. A systolic compression of the proximal coronary sinus may be associated with a risk of dissection particularly in elderly patients. Access to the coronary sinus is best made by two combination systems with a steerable electrophysiology catheter or a telescoping inner catheter. Furthermore, special guiding catheters for the access from the right subclavian vein particularly to upgrade right-sided pacemakers and ICD systems have been developed. Complex, i.e. sharp-angled and corkscrew veins may only serve as target veins, if sharp-angled angiography catheters and over the wire technique are used. The pseudobipolar stimulation against the ring of the right ventricular lead has been developed for the safe function of a CRT defibrillator. This design is associated with an anodal stimulation of the right ventricle, which might result in clinical non-responders especially in patients with optimal left ventricular pacing mode (30%). For this reason, coronary sinus leads should basically be designed as bipolar leads.