Transvenous catheter-based approach to epicardial lead implantation for cardiac resynchronization therapy: access to the pericardial space via controlled perforation

Abstract

Purpose Cardiac resynchronization therapy requires optimal positioning of the LV epicardial pacing lead to achieve maximum mechanical benefits. However, the standard lead placement via coronary sinus is technically challenging in dilated hearts and is often limited by vascular anatomy. To overcome these limitations we have developed a novel transvenous catheter-based approach to insert pacing leads into the pericardial space (PS). Methods In six pigs, a Cut-Mullins catheter and Brockenborough needle was transvenously introduced into the right atrium (RA) from the right jugular vein under fluoroscopic guidance; the PS was accessed via a puncture to the RA/SVC, which was confirmed by radiocontrast injections. A guide wire was advanced into the PS through the Brockenborough needle, which was then removed. A passive fixation pacing lead was advanced into the PS over a wire (left panel). Three weeks later, the lead location was confirmed by fluoroscopy, and the animals were euthanized for tissue analysis. Results The procedure was well tolerated, and despite a mild pericardial effusion, no acute hemodynamic compromise was noted. Postmortem examination revealed that the PS puncture site was the RA near the appendage (n=1) and the SVC near the junction of the pericardial transverse sinus (n=5) (middle panel). In two animals, the pericardial effusion was serous within a normal quantity. In one animal, a large fibrono-gelatinous effusion was noted. No infection of the PS was documented. Histological examination at the puncture site showed active inflammation (n=2) (right panel). Conclusions Our transvenous approach to the pericardial space for pacing lead placement is feasible. Future studies should be directed at optimal picture sites, anti-inflammatory strategies, active fixation lead implantation and lead extraction techniques. ![Figure][1] [1]: pending:yes