SUPERIOR APPROACH IMPLANTATION OF ENDOCARDIAL LV LEAD IS EFFECTIVE IN PROVIDING CARDIAC RESYNCHRONIZATION THERAPY

Abstract

Transvenous Coronary Sinus (CS) placement of a left ventricular (LV) lead is the standard approach to deliver Cardiac Resynchronization Therapy (CRT). A subset of patients remains unable to receive CRT as a result of a failed LV implant, no CS access or CRT nonresponse. We report the first Canadian experience with endocardial LV lead implantation as part of the worldwide ALternate Site Cardiac ReSYNchronization (ALSYNC) Study. Patients with failed CRT CS implant or suboptimal CS anatomy lead placement or CRT non-responders were enrolled. A superior approach was used to perform the atrial transseptal puncture through the fossa ovalis with an RF wire under TEE or intra-cardiac echocardiography guidance. Following this a sheath was placed in the left atrium and a 4Fr active fixation endocardial lead was advanced across the mitral valve and positioned in the appropriate region of the left ventricle. Intravenous heparin was administered during the procedure and was bridged to warfarin with a target INR between 2-3.5.Cardiac function (LVEF, LVEDD), NYHA class, implant data (thresholds, procedure, fluoroscopy times) and complications were collected for analysis. Analysis was performed using the student t-test or Wilcoxon signed-rank test where applicable. Twelve patients (8 male, 4 ischemic, mean age 67±10 years) were enrolled, 11 of whom had successful implantation. The average procedure time was 155±45 min and fluoroscopy time was 33±16 min. There were 2 incidents of hematoma/infection (1 necessitating lead extraction) and one patient had lead dislodgement requiring revision. One patient reported TIA but was managed without recurrent symptoms once crossed over to dabigatran. Endocardial LV lead placement may provide a valuable CRT alternative in patients who may be excluded from conventional CS transvenous approach.