Transseptal endocardial left ventricular lead implantation is safe and effective alternative of conventional resynchronisation therapy

Abstract

Introduction: Transvenous left ventricular (LV) lead positioning via the coronary sinus (CS) sidebranches might be challenging or in some instances impossible, in these cases alternative methods would be preferable. The aim of this study was to investigate the effectiveness and safety of transseptal endocardial left ventricular lead implantation (TELVLI) in severe heart failure patients, and evaluate the long term follow ups of the patients. Objectives: TELVLI was performed in 28 patients (24 men, 61±7 years, NYHA III-IV stage). Methods: Transseptal (TS) puncture was performed via the femoral vein. Intracardiac ulrasound was used to guide the puncture in 21 pts. The site of the puncture was dilated with a 6mm (3 pts), later with an 8 mm balloon (25 pts). After the puncture of the left subclavian vein, an electrophysiological deflectable CS catheter was introduced into the CS sheath. The CS catheter was used to reach the left atrium and the left ventricle through the dilated transseptal puncture hole. In four cases CARTO system was used to find the site of the latest activation, in the other cases right and left ventricular (RV-LV) signals were evaluated and the latest RV-LV delay was determined as latest activation. At the latest LV activation site 65 cm active fixation bipolar lead was screwed into the LV wall. Results: The lead was fixed in the left ventricle in all cases with good pacing threshold values (0,82±0,4 V; 0,4 ms). Puncture complication, pericardial effusion was not observed. Because of intraoperatively started anticoagulation therapy, pocket haematoma was observed postoperatively in three (11%) and needed surgical evacuation in one case (4%). Follow-up is longer than one month in all patients (21±13 months). Significant improvement of the NYHA class was observed in all but one case (96%), on the first month control LV EF was 29±7% vs 36±7%. Early lead dislocation was noticed in three cases (10%), reposition was performed using the original puncture site in two patients, and transvenous implantation was succesfully carried out in the other case. Explantation of the system was necessary because of pocket infection in four cases (14%), in two of these cases TELVLI was carried out succesfully 3 months later. All patients were maintained on anticoagulation therapy either with warfarine or cumarine with INR between 2-3. No thromboembolic complication was noticed during the follow up. Conclusions: TELVLI approach might be an alternative of the surgical epicardial procedure, if transvenous implantation could not be applied, however more evidences and studies are needed to evaluate this method.