Endocardial Lead Research Articles

Management of the late endocardial lead dislocation into the pulmonary trunk.

Management of the late endocardial lead dislocation into the pulmonary trunk.

The Bionic Man: Surgical and Percutaneous Advances in Heart Failure and D-transposition of the Great Arteries

BackgroundModern advances in surgery and percutaneous interventions have resulted in new therapeutic possibilities for end-stage heart failure in congenital heart disease. We present a case of a patient with D-transposition of the great arteries undergoing multiple surgeries and percutaneous interventions for advanced heart failure.DescriptionA 44-year-old man with D-transposition of the great arteries underwent a Blalock-Hanlon septectomy at age 9 days and a Mustard atrial switch procedure at age 3 years. He received an epicardial ventricular pacemaker at age 12 years for high grade atrioventricular (AV) block. He developed supraventricular tachycardia ten years ago, received electrophysiology ablation, and was found to have an inferior vena cava (IVC) baffle leak for which he underwent Amplatzer occluder device placement. Four years ago, he developed superior vena cava (SVC) and IVC baffle stenosis and underwent dilation and covered stent placements in the SVC and IVC baffles. His pacemaker was upgraded to a biventricular implantable cardioverter defibrillator (ICD) utilizing the epicardial ventricular lead and an endocardial lead through the covered stent in the SVC baffle for primary prevention of sudden cardiac death. Due to worsening heart failure despite inotropic support, the patient underwent systemic HeartWare ventricular assist device (VAD) implantation as a bridge to transplantation.DiscussionThe chest X-ray shows a HeartWare ventricular assist device attached to the systemic right ventricle. The biventricular ICD includes endocardial right-atrial lead, ICD lead in the non-systemic left-ventricle, and two epicardial ventricular leads. Multiple sternotomy wires, endotracheal tube and right internal jugular catheter are seen. The stented superior and inferior vena cava baffles and Amplatzer closure device for baffle leak project over the mediastinum.ConclusionSignificant advances in surgery and percutaneous interventions allow for complex therapeutic options for patients with congenital heart disease and advanced heart failure. Modern advances in surgery and percutaneous interventions have resulted in new therapeutic possibilities for end-stage heart failure in congenital heart disease. We present a case of a patient with D-transposition of the great arteries undergoing multiple surgeries and percutaneous interventions for advanced heart failure. A 44-year-old man with D-transposition of the great arteries underwent a Blalock-Hanlon septectomy at age 9 days and a Mustard atrial switch procedure at age 3 years. He received an epicardial ventricular pacemaker at age 12 years for high grade atrioventricular (AV) block. He developed supraventricular tachycardia ten years ago, received electrophysiology ablation, and was found to have an inferior vena cava (IVC) baffle leak for which he underwent Amplatzer occluder device placement. Four years ago, he developed superior vena cava (SVC) and IVC baffle stenosis and underwent dilation and covered stent placements in the SVC and IVC baffles. His pacemaker was upgraded to a biventricular implantable cardioverter defibrillator (ICD) utilizing the epicardial ventricular lead and an endocardial lead through the covered stent in the SVC baffle for primary prevention of sudden cardiac death. Due to worsening heart failure despite inotropic support, the patient underwent systemic HeartWare ventricular assist device (VAD) implantation as a bridge to transplantation. The chest X-ray shows a HeartWare ventricular assist device attached to the systemic right ventricle. The biventricular ICD includes endocardial right-atrial lead, ICD lead in the non-systemic left-ventricle, and two epicardial ventricular leads. Multiple sternotomy wires, endotracheal tube and right internal jugular catheter are seen. The stented superior and inferior vena cava baffles and Amplatzer closure device for baffle leak project over the mediastinum. Significant advances in surgery and percutaneous interventions allow for complex therapeutic options for patients with congenital heart disease and advanced heart failure.

3405Transseptal endocardial left ventricular lead implantation is an effective and feasible method and exerts long lastig beneficial haemodynamical effects after failed CRT implantation

3405Transseptal endocardial left ventricular lead implantation is an effective and feasible method and exerts long lastig beneficial haemodynamical effects after failed CRT implantation

The first successful implantation of an intravenous AAIR pacemaker into autologous extracardiac lateral tunnel Fontan in the child

Patients with a single ventricle have complex anatomy that requires staged palliation which is usually the Fontan procedure. This procedure has undergone a lot of modifications to improve hemodynamics. Despite these efforts, sinus node dysfunction (SND) and bradyarrythmias are still common complications after Fontan operation, therefore there is a need of pacemakers implantation. Unfortunately, the most frequent technique of creating Fontan cannale – the extracardiac lateral tunnel makes the transvenous access to the atrium difficult or impossible to achieve. We report a case of successful implantation of an endocardial atrial lead for SND in patient with an extracardiac autologous Fontan tunnel.

Physiological pacing in young patients with complex congenital heart defects.

Young patients with operated complex congenital heart defects (CHD) often develop sinus node dysfunction (SND) requiring permanent pacing with rate-responsive function. Activity-driven sensors cannot account for nonmovement stress and cannot modulate heart rate physiologically. Closed Loop Stimulation (CLS, Biotronik, Berlin, Germany) is a physiological rate-responsive pacemaker based on the indirect measure of ventricular contractility. No data are available on the effects of such pacing strategy in young patients. We report a series of nine patients with CHD and SND who underwent single-chamber CLS-atrial pacing with endocardial or epicardial lead. During the first 30 days, the pacemaker was programmed in AAI pacing mode and then was switched to CLS-atrial pacing mode. An in-hospital control was scheduled 1-2 months later to evaluate the CLS response to neurovegetative stresses (i.e., nonmovement stress [Stroop color test, handgrip] and exercise stress test) and Holter monitor. CLS pacing was compared with rate-responsive accelerometer-driven pacing (AAIR). At telemetric interrogation, CLS pacing showed a more physiological pattern of 24-h heart rate trends than accelerometer sensors. The data obtained during nonmovement/exercise stress demonstrated a physiological increase in the pacing rate with CLS, in synergy with spontaneous events. The accelerometer sensor histogram, during nonmovement stress, showed a "nonresponse" behavior (only lower rate events), and during exercise test showed most events in lower rate range. Holter monitoring showed increase of average and maximum heart rate compared with AAIR. In young CHD patients, endocardial/epicardial CLS-atrial pacing demonstrated a physiological response of heart rate to neurovegetative and physical stresses.

Systematic review and meta-analysis of left ventricular endocardial pacing in advanced heart failure: Clinically efficacious but at what cost?

Cardiac resynchronization using a left ventricular (LV) epicardial lead placed in the coronary sinus is now routinely used in the management of heart failure patients. LV endocardial pacing is an alternative when this is not feasible, with outcomes data sparse. To review the available evidence on the efficacy and safety of endocardial LV pacing via meta-analysis. EMBASE, MEDLINE, and COCHRANE databases with the search term "endocardial biventricular pacing" or "endocardial cardiac resynchronization" or "left ventricular endocardial" or "endocardial left ventricular." Comparisons of pre-and post-QRS width, LV ejection fraction (LVEF), and New York Heart Association (NYHA) functional classification was performed, and mean differences (and respective 95% confidence interval [CI]) applied as a measurement of treatment effect. Fifteen studies, including 362 patients, were selected. During a mean follow-up of 40 ± 24.5 months, death occurred in 72 patients (11 per 100 patient-years). Significant improvements in LVEF (mean difference 7.9%, 95% CI 5-10%, P<0.0001; I2 =73%), QRS width (mean difference: -41% 95% -75 to -7%; P<0.0001; I2 =94%), and NYHA class (mean difference: -1.06, 95% CI -1.2 to -0.9, P<0.0001; I2 =60%), (all P<0.0001) occurred. Stroke rate was 3.3-4.2 per 100 patient-years, which is higher than equivalent heart failure trial populations and recent meta-analysis that included small case series. LV endocardial lead implantation is a potentially efficacious alternative to CS lead placement, but preliminary data suggest a potentially higher risk of stroke during follow-up when compared to the expected incidence of stroke in similar cohorts of patients.

P1135Long termexperience of the efficacy and safety of the transseptal endocardial left ventricular lead implantation after failed CRT implantation

P1135Long termexperience of the efficacy and safety of the transseptal endocardial left ventricular lead implantation after failed CRT implantation

Cardiac electronic implantable devices after tricuspid valve surgery

The demand for tricuspid valve (TV) surgery has increased continuously in the last years. Recent registry data have confirmed that TV repair or replacement carry an increased risk of conduction disorders requiring permanent pacemaker implantation, specifically for patients having multivalve surgery. The implantation of an endocardial right ventricular lead in those patients may impair TV function, and some other approaches may be discussed to avoid traversing the valve. This contemporary review describes the different options currently available for patients requiring pacemaker or defibrillation leads implantation after TV surgery.

Transseptal approach to the implantation of cardiac resynchronization therapy

Introduction. In patients with cardiac resynchronization therapy left ventricular lead is usually placed through a tributary vein of the coronary sinus. However, when this approach failed, the atrial transseptal approach is mostly used for endovascular left ventricular lead placement, but it is quite difficult to perform. Case report. 59-years-old patient, male, was hospitalized due to endovascular left ventricular lead placement by atrial transseptal approach, after failed attempt via coronary sinus vein. Non-ischemic dilated cardiomiopathy was verified 1 year ago. Endoventricular lead was introduced by left subclavian approach and advanced through the previously punctured hole in the left atrium cavity and over mitral valve placed in posterolateral part of left ventricular. Both right ventricular defibrillator lead and atrial electrode were implanted routinely in the right ventricle septum and right atrial appendage. Conclusion. Left ventricular endocardial lead implantation by atrial transseptal approach is a feasible and safe in patients with previously failed implantation via tributary vein of the coronary sinus.

P547010 years experience of the efficacy and safety of the transseptal endocardial left ventricular lead implantation - An alternative technique in special cases of failed cardiac resynchronization therapy

P547010 years experience of the efficacy and safety of the transseptal endocardial left ventricular lead implantation - An alternative technique in special cases of failed cardiac resynchronization therapy

Constrictive pericarditis from an endocardial pacemaker lead

Constrictive pericarditis secondary to endocardial pacemaker inflammation, without associated pericardial effusion or infection, has yet to be described in the literature. We present a case of a 42-year-old man who...

37 Thromboembolic events in left ventricular endocardial pacing: long-term outcomes from a multicentre uk registry

Background Endocardial left ventricular (LV) pacing is an effective alternative in patients with failed coronary sinus lead. However, the major concern is the unknown long-term thromboembolic risk and much of the data has come from a small number of centres. We examined the safety and efficacy of endocardial LV pacing across 4 UK centres, to determine the long-term thromboembolic risk. Methods and Results Independent prospective registries from four UK centres were combied to include 68 consecutive patients from 2010–2015. Medical records were reviewed and patients were contacted for follow-up. Thromboembolic events were confirmed on imaging. Baseline patient demographics are shown in Table 1. 65% patients were already anticoagulated (39 AF, 1 DVT, 2 prosthetic valve, 2 previous LV thrombus). Mean CHADS2VASC2 score for the cohort was 3.5. 44% patients had trans-ventricular LV lead. The mean procedure and fluoroscopy times were 200±120 and 32±28 min. 75% had a silicone-insulated pacing lead. Post-procedure, three patients had haematomas and one had tamponade requiring pericardial drain. Functional improvement was noted with decrease in mean NYHA from 3.5±1 to 2.1±1.2 (p=0.001) and increase in LVEF from 26.5±12 to 34±18.1 (p=0.005) over a 20 month follow-up. Re-do procedure due to lead displacement was required in two patients. One patient underwent system extraction and surgical epicardial lead after device infection. The ischaemic stroke rate, defined as transient or permanent loss of function associated with imaging confirmation of a cerebral infarct in the appropriate territory, occurred in 4 patients (6%) providing an annual event rate of 3.6%. In multivariate analyses, the only significant correlation with the risk of CVA was sub-therapeutic INRs (p Conclusion Endocardial LV lead in heart failure patients has a good success rate at 1.6 year follow-up. However, it is associated with a modest thromboembolic risk largely due to sub-therapeutic anticoagulation. These results have potential for improvement and newer oral anticoagulants might play a role in this setting.

両側鎖骨下静脈閉塞を合併した成人先天性完全房室ブロック症例のペースメーカ治療の経験

症例は38歳男性で，新生児期に先天性完全房室ブロックに対し左開胸，心外膜リードによるペースメーカ治療を施行された．成人期に経静脈的心内膜リードへ変更を試みるも両側鎖骨下静脈閉塞していたため不成功に終わった．心外膜リードの閾値が上昇したため今後のシェネレータ消耗を考慮し，今回右開胸経右房的心内膜リードに変更し良好な結果を得た．右開胸経右房的心内膜リード植え込み術は，上大静脈閉塞・両側鎖骨下静脈閉塞例に対する有効な加療の1つと考えた．

Successful transvenous extraction of an endocardial lead more than 35 years old using mechanical systems

Successful transvenous extraction of an endocardial lead more than 35 years old using mechanical systems

High dielectric material in MRI: Numerical assessment of the reduction of the induced local power on implanted cardiac leads.

High dielectric materials (HDM) have been proposed in magnetic resonance imaging (MRI) to increase the signal-to-noise ratio (SNR) of the images acquired while reducing the radiofrequency (RF) absorption in tissue. The aim of this study is to assess the potential merit of using HDM to reduce power induced at the tip of an endocardial lead in patients undergoing MRI. Numerical simulations were performed using a commercial finite-differences time-domain (FDTD) software to model the RF field generated by a birdcage body coil at 64 MHz on a human body model. Two HDM pads were placed between the coil and the body model, and their effect was evaluated in terms of local induced power at the tip of a pacemaker lead. Two different patient imaging positions inside the coil (i.e., head & thorax) were studied. In both cases, the use of HDM allowed reducing the induced power (i.e., 57% reduction with head landmark, 68% with thorax landmark), while maintaining the same magnitude of B1 RMS at the isocenter of the coil. Additionally, when the HDM pads were placed at the head landmark, there was a significant decrease in the local-induced power at the tip of the implant path (58%). Conversely, there was only a 9% decrease when pads were placed at the thorax landmark. In conclusion, the study shows that when the implant is not included in the volume surrounded by the HDM, pads placed between the RF coil and the patient allow obtaining the same magnitude of B1-field with a lower input power of the RF coil, reducing significantly the local induced power around the implant. Conversely, if the implant is included in the volume surrounded by the HDM, the use of HDM can still reduce the input power necessary to obtain the same magnitude of B1-field, but the effect on the local induce power at the implant is lower in magnitude.

Optimized Left Ventricular Endocardial StimulationIs Superior to Optimized EpicardialStimulation in Ischemic Patients WithPoor Response to Cardiac ResynchronizationTherapy: ACombined Magnetic Resonance Imaging, ElectroanatomicContact Mapping, and Hemodynamic Study toTarget Endocardial Lead Placement.

ObjectivesThe purpose of this study was to identify the optimal pacing site for the left ventricular (LV) lead in ischemic patients with poor response to cardiac resynchronization therapy (CRT).BackgroundLV endocardial pacing may offer benefit over conventional CRT in ischemic patients.MethodsWe performed cardiac magnetic resonance, invasive electroanatomic mapping (EAM), and measured the acute hemodynamic response (AHR) in patients with existing CRT systems.ResultsIn all, 135 epicardial and endocardial pacing sites were tested in 8 patients. Endocardial pacing was superior to epicardial pacing with respect to mean AHR (% change in dP/dtmax vs. baseline) (11.81 [-7.2 to 44.6] vs. 6.55 [-11.0 to 19.7]; p = 0.025). This was associated with a similar first ventricular depolarization (Q-LV) (75 ms [13 to 161 ms] vs. 75 ms [25 to 129 ms]; p = 0.354), shorter stimulation–QRS duration (15 ms [7 to 43 ms] vs. 19 ms [5 to 66 ms]; p = 0.010) and shorter paced QRS duration (149 ms [95 to 218 ms] vs. 171 ms [120 to 235 ms]; p < 0.001). The mean best achievable AHR was higher with endocardial pacing (25.64 ± 14.74% vs. 12.64 ± 6.76%; p = 0.044). Furthermore, AHR was significantly greater pacing the same site endocardially versus epicardially (15.2 ± 10.7% vs. 7.6 ± 6.3%; p = 0.014) with a shorter paced QRS duration (137 ± 22 ms vs. 166 ± 30 ms; p < 0.001) despite a similar Q-LV (70 ± 38 ms vs. 79 ± 34 ms; p = 0.512). Lack of capture due to areas of scar (corroborated by EAM and cardiac magnetic resonance) was associated with a poor AHR.ConclusionsIn ischemic patients with poor CRT response, biventricular endocardial pacing is superior to epicardial pacing. This may reflect accessibility to sites that cannot be reached via coronary sinus anatomy and/or by access to more rapidly conducting tissue. Furthermore, guidance to the optimal LV pacing site may be aided by modalities such as cardiac magnetic resonance to target delayed activating sites while avoiding scar.

216-67: Efficacy of surgical treatment of moderate to severe mitral regurgitation in patients scheduled for cardiac resynchronization therapy

Purpose of the study; Mitral regurgitation (MR) in heart failure (HF) patients is generally associated with a poor prognosis. Cardiac resynchronization therapy (CRT) can reduce the degree of MR, improve symptoms and prognosis of HF patients. However, the significant residual MR after CTR is considered as a predictor of poor prognosis. The purpose of this study is to evaluate the clinical efficacy and prognosis of surgical treatment of moderate to severe MR in patients scheduled for CRT. Method used; A total of 23 consecutive patients scheduled for CRT with moderate to severe MR were enrolled between 2008 and 2015. 13 patients were performed mitral valve surgery (valvuloplasty 5 (38%), valve replacement 8 (62%); surgical group), and 10 patients were not performed (non-surgical group). In the surgical group, also coronary artery bypass 7 (54%), tricuspid annuloplasty 8 (62%), left ventricular epicardial lead placement 10 (77%) were performed simultaneously, and CRT were completed by endocardial lead added. All patients were evaluated MR change and major adverse cardiac events after CRT. Summary of results; MR improvement after CRT was significantly higher in the surgical group (surgical group 13 (100%) vs non-surgical group 3 (30%); p < 0.01), and MR worsening (0 (0%) vs 4 (40%); p < 0.05) and moderate to severe residual MR (1 (8%) vs 7 (70%); p < 0.01) were significantly lower in the surgical group.During the follow-up period (mean 38 ± 19 months), there were no significant between group differences in the total mortality rate, but cardiac death (2 (15%) vs 7 (70%); p < 0.05), and HF death (1 (8%) vs 6 (60%); p < 0.05) were significantly lower in the surgical group. Furthermore the surgical group showed a significantly higher rate of survival free of HF readmission (62.5% vs 22.2%; p < 0.05). Conclusion; Surgical treatment of moderate to severe MR in patients scheduled for CRT can significantly reduce the residual MR after CRT, may contribute to improve the prognosis and quality of life.

Transseptal Leftventricular Endocardial Pacing is an Alternative Technique in Cardiac Resynchronization Therapy. One Year Experience in a High Volume Center.

In patients receiving cardiac resynchronization therapy (CRT), failure rate to implant the left ventricular (LV) lead by the traditional trans-venous approach is 4-8%. Surgical epicardial implantation is considered as an alternative, but this technique is not without morbidity. Evidence from case documentation and from small trial batches demonstrated the viability of endocardial LV lead implantation where surgical epicardial lead placement is not applicable. Four patients were implanted with endocardial LV lead using the transseptal atrial approach after unsuccessful transvenous implantation. Implantation of an endocardial active fixation LV leads was successful in all patients with stable electrical parameters immediately after implantation and over the follow-up period. All patients received anticoagulation therapy in order to target the international normalized ratio of 2.5-3.5 and have not experienced any thromboembolic, hemorrhagic events, or infection. Follow-up echocardiography indicated significant improvement of LV systolic function (24 + 4.9 to 32 + 5.1 %, P = 0.023) with a notable improvement of the functional status. Endocardial left ventricular lead implantation can be a valuable and safe alternative technique to enable LV stimulation in high surgical risk patients where standard coronary sinus implant is unsuccessful.

Why the Authors Use Cardiac Resynchronization Therapy with Defibrillators.

Cardiac resynchronization therapy (CRT) improves left ventricular function, especially in patients with left bundle branch block or those receiving chronic right ventricular pacing. CRT is typically accomplished by placing a right ventricular endocardial pacing lead and a left ventricular pacing lead via the coronary sinus to a coronary vein overlying the lateral or posterolateral left ventricle. CRT can be combined with an implantable defibrillator or with a pacemaker. Limited data are available to compare these two versions of CRT head to head. This review summarizes the relevant trials and meta-analyses regarding these two forms of CRT.

Tricuspid Regurgitation Following Implantation of Endocardial Leads: Incidence and Predictors.

Endocardial leads, permanent pacemaker (PPM), or implantable cardioverter defibrillator (ICD) placed across the tricuspid valve can lead to tricuspid regurgitation (TR). The reported incidence of this complication has varied widely. There are limited data predicting which patients will develop this complication. This study sought to describe the incidence of worsening TR post-PPM or ICD and to identify patient-specific predictors of increased TR following lead placement. Patients (N = 382) who received a PPM or ICD from January 1, 2006 to December 31, 2010 and had echocardiograms both within 365 days prior to and up to 1,200 days after device placement were studied. TR was assessed on a 6-point scale (none/trace, mild, mild to moderate, moderate, moderate to severe, severe). Primary outcome was a two-grade increase in the severity of TR. Echocardiographic and clinical predictors of worsening TR were examined using multivariate regression. A two-grade increase in TR occurred in 10.0% of our patient population. Age, lead position, atrial fibrillation, right atrial (RA) area, right ventricular systolic pressure (RVSP), left atrial area, and severity of mitral regurgitation were univariate predictors of worsening TR post lead placement. In the multivariate analysis, predevice RA area and RVSP were associated with increased TR after endocardial lead placement. Percentage of time spent pacing did not appear to be associated with increased TR. The incidence of increased TR postendocardial lead placement was 10.0%; this is lower than prior estimates. Predevice RA area and RVSP are predictors of increased TR after lead placement.