Coronary Sinus Lead Research Articles

New pacing strategies for heart failure

In patients with areduced left ventricular (LV) systolic function (ejection fraction < 35%) and aleft bundle branch block with a QRS duration > 130 ms, cardiac resynchronization therapy (CRT) can contribute to an improvement in the quality of life and areduction in mortality. The resynchronization is mostly achieved by pacing via an epicardial LV lead in the coronary sinus; however, this approach is often limited by the patient's venous anatomy and an increase in the stimulation threshold over time. In addition, up to 30% of patients do not respond to the intervention. New treatment approaches involve direct stimulation of the conduction system by pacing of the bundle of His or left bundle branch. This enables a more physiological propagation of the stimulus. Pacing of the left bundle branch is achieved by advancing the lead into the right ventricle and screwing it deep into the interventricular septum. Due to the relatively large target area of the left bundle branch the success rate is very high (currently > 90%). Observational studies have shown agreater reduction in the QRS duration, amore pronounced improvement in systolic function and alower hospitalization rate for heart failure associated with conduction system pacing compared to CRT using acoronary sinus lead. These findings have been confirmed in small randomized trials. Therefore, the use of left bundle branch pacing should be considered not only as abail out in the case of failed resynchronization using coronary sinus lead placement but increasingly also as an initial pacing strategy. The results of the first large randomized trials are expected to be released in late 2024.

Selection of candidates for cardiac resynchronization therapy and implantation management: an Italian survey promoted by the Italian Association of Arrhythmology and Cardiac Pacing.

Cardiac resynchronization therapy (CRT) represents an effective heart failure treatment, associated with reduction in mortality and heart failure hospitalizations. This Italian survey aimed to address relevant CRT issues. An online survey was administered to AIAC members. One hundred and five electrophysiologists participated, with a median of 40 (23-70) CRT implantations/year (33% in high-volume centres). Forty-five percent of respondents (especially working in high-volume centres) reported an increase in CRT implantations in the last 2 years, in 16% a decrease, and in 38% CRT remained stable. Seventy-five percent of respondents implanted CRT only in patients with European Heart Rhythm Association (EHRA) class I indications. All operators collected ECG and echocardiography before implantation. Eighty-five percent of respondents selected coronary sinus target vein empirically, whereas 10% used mechanical and/or electrical delay techniques. Physicians working in high-volume centres reported a lower failure rate compared with others (16 vs. 34%; P = 0.03). If the coronary sinus lead could not be positioned in the target branch, 80% placed it in another vein, whereas 16% opted for a surgical approach or for conduction system pacing (CSP). Eighty percent accomplished CRT optimization in all patients, 17% only in nonresponders. Regarding anticoagulation, high agreement with EHRA guidelines emerged. CRT represents a valid therapeutic option in heart failure treatment. Nowadays, CRT implantations remain stable and are mainly performed in patients with class I indications. ECG remains the preferred tool for patient selection, whereas imaging is increasingly used to determine the left pacing target area. In most patients, the left ventricular lead can be successfully positioned in the target vein, but in some cases, the result can be unsatisfactory; however, the decision to explore alternative resynchronization approaches is rarely pursued.

Comparison of long-term risk of device-related complications between left bundle branch area pacing and biventricular pacing in candidates for resynchronization therapy

Abstract Introduction Cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) is a well established therapy in patients with reduced left ventricular ejection fraction (LVEF), heart failure, and wide QRS. Left bundle branch area pacing (LBBAP) has recently been shown to be a feasible and effective alternative to BVP. Comparative data on the risk of complications between LBBAP and BVP among CRT candidates are lacking. Purpose The aim of this study was to compare the long-term risk of device-related complications between LBBAP and BVP in a cohort of patients undergoing CRT. Methods Prospective, multicenter, observational study enrolling 668 consecutive patients (71.2±10.0 years, 52.2% male, 59.4% NYHA class &amp;gt;II), with LVEF ≤35% (mean 33.4±4.3%) who underwent BVP (n=560) or LBBAP (n=108) for the first time for Class I or II indications for CRT from January 2020 to June 2023 at 6 Italian centers. Propensity matching for baseline characteristics yielded 90 matched pairs. Rate and nature of device-related complications occurring during follow-up were prospectively collected and compared between the two groups. Results During a mean follow-up of 18 months, device-related complications were observed in 14 patients: 11 in BVP (12.2%), and in 3 in LBBAP (3.3%) (p=0.026). Compared to BVP patients, LBBAP patients showed a higher cumulative survival free from first device–related complication (Figure). Complications related to coronary sinus lead were most frequently observed in BVP patients (36.4% of all complications). The rate of overall lead-related complications was 6.7 and 2.2% in BVP and LBBAP patients, respectively (p=0.149). Conclusion LBBAP was associated with a lower long-term risk of device-related complications compared with BVP in patients with CRT indications.

Extraction of His Bundle Pacing Lead: More Difficult than Coronary Sinus Lead Extraction: An Analysis of 3897 Lead Extraction Procedures Including 27 His and 253 Coronary Sinus Lead Removals.

Experience with the transvenous extraction of leads used for His bundle pacing (HBP) is limited. Analysis of 3897 extractions including 27 HBP and 253 LVP (left ventricular pacing) leads. The main reason for HBP lead extraction was lead failure (59.26%). The age of HBP and LVP leads (54.52 vs. 50.20 months) was comparable, whereas procedure difficulties were related to the LVP lead dwell time. The extraction of HBP leads > 40 months old was longer than the removal of younger leads (8.57 vs. 3.87 min), procedure difficulties occurred in 14.29%, and advanced tools were required in 28.57%. There were no major complications. The extraction time of dysfunctional or infected leads was similar in the HBP and LVP groups (log-rank p = 0.868) but shorter when compared to groups with other leads. Survival after the procedure did not differ between HBP and LVP groups but was shorter than in the remaining patients. 1. HBP is used in CRT-D systems for resynchronisation of the failing heart in 33.33%. 2. Extraction of HBP leads is most frequently performed for non-infectious indications (59.26%) and most often because of lead dysfunction (33.33%). 3. The extraction of "old" (>40 months) HBP leads is longer (8.57 vs. 3.87 min) and more difficult than the removal of "young" leads due to unexpected procedure difficulties (14.29%) and the use of second line/advanced tools (28.57%), but it does not entail the risk of major complications and procedure-related death and is comparable to those encountered in the extraction of LVP leads of a similar age. 4. Survival after lead extraction was comparable between HBP and LVP groups but shorter compared to patients who underwent the removal of other leads.

Complications of left bundle branch area pacing compared with biventricular pacing in candidates for resynchronization therapy: Results of a propensity score–matched analysis from a multicenter registry

BackgroundCardiac resynchronization therapy (CRT) with biventricular pacing (BVP) is a well-established therapy in patients with reduced left ventricular ejection fraction, heart failure, and left bundle branch block. Left bundle branch area pacing (LBBAP) has recently been shown to be a feasible and effective alternative to BVP. Comparative data on the risk of complications between LBBAP and BVP among patients undergoing CRT are lacking. ObjectiveThe aim of this study was to compare the long-term risk of procedure-related complications between LBBAP and BVP in a cohort of patients undergoing CRT. MethodsThis prospective, multicenter, observational study enrolled 668 consecutive patients (mean age 71.2 ± 10.0 years; 52.2% male; 59.4% with New York Heart Association class III-IV heart failure symptoms) with left ventricular ejection fraction 33.4% ± 4.3% who underwent BVP (n = 561) or LBBAP (n = 107) for a class I or II indication for CRT. Propensity score matching for baseline characteristics yielded 93 matched pairs. The rate and nature of intraprocedural and long-term post-procedural complications occurring during follow-up were prospectively collected and compared between the 2 groups. ResultsDuring a mean follow-up of 18 months, procedure-related complications were observed in 16 patients: 12 in BVP (12.9%) and 4 in LBBAP (4.3%) (P = .036). Compared with patients who underwent LBBAP, those who underwent BVP showed a lower complication-free survival (P = .032). In multivariate analysis, BVP resulted an independent predictive factor associated with a higher risk of complications (hazard ratio 3.234; P = .042). Complications related to the coronary sinus lead were most frequently observed in patients who underwent BVP (50.0% of all complications). ConclusionLBBAP was associated with a lower long-term risk of device-related complications compared with BVP in patients with an indication for CRT.

Multilevel Venous Obstruction in Patients with Cardiac Implantable Electronic Devices.

Background and Objectives: The nature of multilevel lead-related venous stenosis/occlusion (MLVSO) and its influence on transvenous lead extraction (TLE) as well as long-term survival remains poorly understood. Materials and Methods: A total of 3002 venograms obtained before a TLE were analyzed to identify the risk factors for MLVSO, as well as the procedure effectiveness and long-term survival. Results: An older patient age at the first system implantation (OR = 1.015; p < 0.001), the number of leads in the heart (OR = 1.556; p < 0.001), the placement of the coronary sinus (CS) lead (OR = 1.270; p = 0.027), leads on both sides of the chest (OR = 7.203; p < 0.001), and a previous device upgrade or downgrade with lead abandonment (OR = 2.298; p < 0.001) were the strongest predictors of MLVSO. Conclusions: The presence of MLVSO predisposes patients with cardiac implantable electronic devices (CIED) to the development of infectious complications. Patients with multiple narrowed veins are likely to undergo longer and more complex procedures with complications, and the rates of clinical and procedural success are lower in this group. Long-term survival after a TLE is similar in patients with MLVSO and those without venous obstruction. MLVSO probably better depicts the severity of global venous obstruction than the degree of vein narrowing at only one point.

Visualization of Left Ventricular Endocardium Activation Time during Cardiac Conduction System Pacing

Introduction. Right ventricular myocardial pacing leads to asynchronous contraction of the left ventricle (LV) and can impair its contractility over time. Stimulation of the conduction system of the heart ensures physiological activation of the ventricles.&#x0D; The aim. To visualize the pattern of propagation of the electrical front on the activation map of the LV endocardium during conduction system pacing and during right ventricular myocardial pacing.&#x0D; Materials and methods. In two patients with the conduction system pacing, who were operated at the National Amosov Institute of Cardiovascular Surgery, invasive LV activation mapping was performed on various options of cardiac pacing using the EnSite Precision TM navigation system. One patient with complete atrioventricular block had nonselective His bundle pacing. The second patient had dilated cardiomyopathy and indications for cardiac resynchronization therapy and ablation of the atrioventricular junction due to chronic tachyform of atrial fibrillation. After an unsuccessful attempt to place LV lead in coronary sinus, a lead for left bundle branch pacing was implanted. Different activation maps of the LV endocardium were built in two patients with two types of cardiac pacing: right ventricular myocardial pacing and cardiac conduction system pacing.&#x0D; Results. The total LV endocardial activation time was significantly different in the two studied patients with different pacing options. In a patient with non-selective stimulation of His bundle, the total LV endocardial activation time was 43 ms (QRS width 126 ms, the interval from the stimulus to the peak of the R wave in lead V6 78 ms). After switching to right ventricular myocardial pacing with a decrease in the pacing amplitude, the total LV endocardial activation time prolonged to 90 ms (QRS width 165 ms, the interval from the stimulus to the peak of the R wave in lead V6 117 ms). In a patient with left bundle branch pacing, total LV endocardial activation time was 51 ms (QRS width 160 ms, the interval from the stimulus to the peak of the R wave in lead V6 66 ms). With switching exclusively to right ventricular pacing the total LV endocardial activation time prolonged to 93 ms (stimulated QRS width 180 ms). At the same time, the activation pattern of the LV endocardium was significantly different, since the right ventricular lead was located closer to the apex.&#x0D; Conclusions. Conduction system pacing provides rapid physiological LV activation and potentially avoids the negative consequences of asynchronous slow ventricular activation during right ventricular pacing.

Effective and safe long-term transvenous extraction of the novel active fixation coronary sinus lead

Active fixation systems for leads in the coronary system minimize the risk of micro and macro dislodgement. However, extracting these leads is riskier than in the case of leads of passive fixation. This was confirmed by the results of the extraction of Medtronic StarFix lead. The new Medtronic 20066 Attain Stability lead was designed to combine the stability of fixation with the feasibility of extraction. In our report, we present the case of extraction of 36th month Medtronic 20066 Attain Stability lead. The lead was safely and entirely extracted with simple traction after securing with a locking stylet without visible damage to either the fixating mechanism or coronary veins. Our experience suggests that extraction of the Medtronic 20066 Attain Stability lead even after relatively long dwelling time seems to be substantially simpler and safer than the extraction of Medtronic StarFix lead.

His-Purkinje Conduction System Pacing Optimized Trial of Cardiac Resynchronization Therapy vs Biventricular Pacing: HOT-CRT Clinical Trial

BackgroundHis-Purkinje conduction system pacing (HPCSP) using His bundle pacing (HBP) or left bundle branch pacing (LBBP) has emerged as an alternative to biventricular pacing (BVP) in patients requiring cardiac resynchronization therapy (CRT). ObjectivesThe aim of the study was to compare the feasibility and clinical efficacy of HOT-CRT (His-Purkinje conduction system pacing Optimized Trial of Cardiac Resynchronization Therapy) with BVP in patients with heart failure, reduced ejection fraction, and indication for CRT. MethodsThis was a prospective, randomized, controlled trial of HOT-CRT and BVP in patients with LVEF <50% and indications for CRT. If HPCSP resulted in incomplete electrical resynchronization, a coronary sinus (CS) lead was added. The primary outcome was the change in left ventricular ejection fraction (LVEF) at 6 months. The primary safety endpoint was freedom from major complications. ResultsA total of 100 patients (female 31%, aged 70 ± 12 years, LVEF 31.5% ± 9.0%) were randomized. HOT-CRT was successful in 48 of 50 (96%) and BVP-CRT in 41 of 50 (82%) patients (P = 0.03). QRS duration significantly decreased from 164 ± 26 ms to 137 ± 20 ms with HOT-CRT and 166 ± 28 ms to 141 ± 19 ms with BVP. Fluoroscopy results (18.8 ± 12.4 min vs 23.8 ± 12.4 min, P = 0.05) and procedure duration (119 ± 42 min vs 114 ± 36 min, P = 0.5) were similar. The primary outcome of change in LVEF at 6 months was greater in HOT-CRT than in BVP (12.4% ± 7.3% vs 8.0% ± 10.1%, P = 0.02). The primary safety endpoint was similar (98% vs 94%, P = 0.62). Echocardiographic response of improvement in LVEF >5% occurred in 80% vs 61% (P = 0.06). Complications occurred in 3 (6%) in HOT-CRT vs 10 (20%) in BVP (P = 0.03). ConclusionsHPCSP-guided CRT resulted in greater change in LVEF compared with BVP. Randomized clinical trials with long-term follow-up are necessary. (His-Purkinje Conduction System Pacing Optimized Trial of Cardiac Resynchronization Therapy [HOT-CRT]; NCT04561778)

Resynchronization for shifting conduction patterns - When a coronary sinus lead is not enough

Resynchronization for shifting conduction patterns - When a coronary sinus lead is not enough

Comparison of electrocardiographic parameters between left bundle optimized cardiac resynchronization therapy (LOT-CRT) and left bundle branch pacing-cardiac resynchronization therapy (LBBP-CRT).

In patients undergoing cardiac resynchronization therapy using left bundle branch area pacing (LBBP-CRT), the addition of a coronary sinus lead, that is, Left bundle optimized CRT (LOT-CRT) might confer additional benefits. To compare the electrocardiographic characteristics between LBBP-CRT and LOT-CRT MATERIALS AND METHODS: Patients with non-ischemic cardiomyopathy (NICMP) and left bundle branch block (LBBB) with left ventricular ejection fraction<35% who underwent implantation of an atrial lead, a left bundle lead, and a coronary sinus lead were included in this prospective study. Digital 12-lead electrocardiograms were recorded in three pacing modes-AAI, DDD with pacing from the LBB lead (LBBP-CRT), and DDD with pacing from both left bundle and coronary sinus leads (LOT-CRT). QRS duration (QRSd), QRS area, QT interval, and T peak-T end (TpTe) intervals were compared. Among 24 patients, QRSd reduced from 167±21.2ms to 134.5±23.6ms with LBBP-CRT (p<.001) and 129.5±18.6ms with LOT-CRT (p<.001) without a significant difference between LBBP-CRT and LOT-CRT (p=.15). Patients with QRS duration with LBBP-CRT>131ms showed a significant reduction in QRSd with LOT-CRT (p=.03). QT interval was reduced with both modes of CRT. LOT-CRT was associated with a greater reduction in QRS area (p=.001), TpTe interval (p=.03), and TpTe/QT ratio (p=.013) compared to LBBP-CRT. In patients with NICMP and LBBB, there was no significant difference in QRSd with LOT-CRT compared to LBBP-CRT. However, in patients with QRSd>131ms after LBBP-CRT, LOT-CRT resulted in a significantly narrower QRS.

P255 A GOOD PERSPECTIVE NEEDS TWO POINT OF VIEW: TRANSVENOUS CRT–D LEAD EXTRACTION COMPLICATED BY INTRAOSSEUS COURSE OF THE CORONARY SINUS LEAD

Abstract A 66 year old woman with dilated cardiomyopathy, carrier of CRT–D device in secondary prevention since 2013 and a mitralic mechanical prosthesis, suffered of CIED infection, confirmed by PET imaging exam. She was scheduled in our Hospital Unit for transvenous lead extraction. The procedure was performed by the subclavian approach, and the transvenous lead extraction was staged using mechanical telescopic sheats. After the extraction of the atrial and ventricular leads, the advance of the sheats was hampered by tenacious adherences along the site of vascular subclavian access of the coronary sinus lead. Firstly the portion of the lead running inside the coronary sinus was retracted with a pigtail by femoral vein approach. The inability to pass over the tenacious adherences at the point of the subclavian vein access were overcome expanding the surgical field with the help of the Vascular Surgeon, finding out that the adherence was determined by the presence of an osteophyte embracing the lead to the clavicle. The osteophyte was then surgically removed and the lead was finally extracted by jugular vein access. In this case the CIED leads were implanted using a intrathoracic subclavian venous access, where the vein lies behind the medial region of the clavicle. This approach could rarely lead to a periosteal penetration during needle advance that can generate osteophytes between the lead and the bone. In those circumstances the transvenous lead extraction could become extremely complicated, whatever technique is used.

PO-04-102 LOSS OF LEFT VENTRICULAR CAPTURE DURING ACUTE HEMOPERICARDIUM

Loss of left ventricular capture from a chronic quadripolar coronary sinus lead was observed during development of an iatrogenic cardiac pericardial effusion. Subsequently, during pericardiocentesis left ventricular capture was reobtained. Reaccumulation of hemopericardium again resulted in repeated observable loss of LV capture. No previous documentation in literature review is noted. This phenomenon may have critical clinical value in predicting significant pericardial effusion or affect the clinical value of cardiac resynchronization therapy in patients with chronic pericardial effusions. To demonstrate a previously undocumented clinical phenomenon that significantly affect patient care and outcomes. N/A We present a case of an 83 YO male patient with iatrogenic pericardial effusion during transseptal puncture resulting in cardiac tamponade and observed loss of left ventricular capture. Our patient presented for Watchman implantation however after transseptal puncture prior to Watchman implantation hemopericardium developed with cardiac tamponade. Loss of LV capture resulted in RV only pacing until pericardiocentesis with placement of a pericardial drain was placed. After evacuation of 80cc volume and gross reduction in pericardial effusion size on transesophageal echocardiography with resolution of cardiac tamponade, LV capture was again noted. Device interrogation revealed stable lead thresholds. During clinical followup, reaccumulation of hemopericardium again resulted in loss of LV capture prior to clinical tamponade and again resolution of pericardial effusion resulted in regaining biventricular capture. Figure 1: Progressive loss of biventricular capture is noted during pericardial effusion accumulation leading to cardiac tamponade. Hemopericardium may result in loss of left ventricular capture from a chronic coronary sinus lead with stable thresholds. The observed loss of capture occurred prior to clinical cardiac tamponade and may offer an early qualitative measure of significant pericardial effusions.

PO-02-058 USING A NOVEL IN VITRO HUMAN BLOOD LOOP MODEL TO EXPLAIN SCAR TISSUE FORMATION A PHYSICIAN MAY ENCOUNTER IN EXTRACTING CORONARY SINUS LEADS

The Medtronic Attain Stability Model 4798 (ASQ) coronary sinus (CS) lead was designed with an active fixation helix for precise placement and extractability. We sought to understand extractability of ASQ as compared to a lead with 1. favorable extractability such as Medtronic Attain Performa Model 4598, and 2. the Medtronic Star Fix® in which considerable fibrotic tissue growth involves the expanded fixation lobes, making the extraction process very challenging. Typically, animal models are used to understand lead fibrotic tissue growth, however, such studies are of limited value. In this study, we used a novel in vitro human blood loop model to evaluate flow profiles and coagulation response which has shown to be a surrogate to fibrotic tissue growth and scar formation. This model allows for improved control and accelerated test conditions in comparison to animal models. To assess thrombus formation as an early indicator of long-term scar development in three Medtronic CS leads and the impact of CS vein fixation design. In this blood donor study, leads were placed inside a closed loop system representing the average CS diameter. Loops were primed with freshly drawn heparinized human blood, donated via an IRB approved Medtronic blood donor program. Heparin concentration was chosen from prior titration studies to prevent clotting in the loop alone. Experiments were run for five hours at 37°C under continuous flow conditions comparable with known CS flow rates. Change in flow rate over time was measured. Post blood exposure, leads were subjected to histological evaluation. On histologic evaluation the Star Fix® (n=6) showed mean thrombus coverage of 70.8±28% compared to minimal thrombus coverage of 3±1.5% on ASQ (n=6) and 3±1.7% on Performa (n=3) (p < 0.05) (Image 1). At a constant pump speed, the 95th percentile of flow rate drop was 165mL/min with Star Fix® implants compared to only 13mL/min drop with ASQ and 9mL/min with Performa. This novel model demonstrates how lead design can impact flow profiles and subsequent thrombus formation as a surrogate to vascular scar formation. The ASQ has minimal thrombus formation and is comparable to Attain Performa. In contrast, Star Fix® with expanded fixation lobes has considerable flow disruption and thrombus formation consistent with the clinical findings of significant scar formation that can result in a challenging extraction procedure.

PO-04-017 'LEFT' BROKEN AFTER EXERCISE: A CASE OF PAINFUL LBBB SYNDROME SUCCESSFULLY TREATED WITH LEFT BUNDLE BRANCH AREA PACING

The leading causes of new-onset left bundle branch block (LBBB) include coronary artery disease, hypertension, and cardiomyopathies. However, when the LBBB occurs in the absence of ischemia, in a rate-dependent manner, usually with exertion, it constitutes a painful left bundle branch block. Although there are multiple case reports of this entity, the mechanism, pathophysiology, and treatment are not well defined. We intend to raise awareness of this syndrome and highlight our unique treatment approach. NA A 57-year-old male presented to the cardiology clinic with exertional chest pain and palpitations. He underwent an exercise ECG test, surprisingly on stage 2 of Bruce protocol, at around a heart rate of 116 bpm; he started developing LBBB on every other beat. At a heart rate of 125 bpm, he developed persistent LBBB associated with similar symptoms, both of which persisted in the recovery phase (Figure 1). His Echocardiogram was normal. Invasive coronary angiography revealed normal coronaries. Previous case reports have shown that cardiac rehabilitation helps to delay the onset of LBBB to a higher heart rate; however, he opted for pacemaker implantation as he had severe exercise limitations. He underwent a biventricular-implantable pacemaker with right atrial, left bundle branch area, and coronary sinus (CS) left ventricular (LV) leads. The pacemaker was programmed DDD60 with a rate adaptive AV interval with a start rate of 80 bpm. This would enable the LBB area pacing above a heart rate of 80 bpm. Within one week of implantation, the patient had a complete resolution of his symptoms. A cardiopulmonary exercise test to assess VO2 with pacing programmed off and then on is scheduled as part of the follow-up. The symptoms of the painful LBBB syndrome can be quite severe, resulting in physical and psychological debilitation. Treatment with a physical exercise regimen has been successful as it delays the LBBB onset to a higher heart rate. However, the patient loses the benefit once they stop exercising. A definitive solution is a pacemaker; there are multiple case reports of His bundle and right ventricular pacing, which successfully treated this syndrome. In this case, we used a unique approach of pacing just the LBBB area; in addition, a CS LV lead was placed, which could be used for an earlier activation of the LV if the patient needs that in the future.

PO-02-024 ANCHOR BALLOON TECHNIQUE AS A RESCUE STRATEGY FOR CHALLENGING CORONARY SINUS CANNULATION: A CASE SERIES

Cardiovascular resynchronization therapy (CRT) improves outcomes in patients with chronic systolic heart failure and interventricular dyssynchrony. However difficult coronary sinus (CS) access due to tortuosity, stenosis or steep angulation can pose challenges to successful left ventricular (LV) lead implantation. Many such cases require surgical epicardial LV lead placement which is more invasive and associated with higher incidence of complications. Despite the use of interventional tools and techniques, such as use of delivery sheaths of varied sizes, Amplatz support wire, vein selectors and snaring, some cases require more advanced techniques such as anchor balloon as a rescue strategy to ensure successful LV lead placement. We describe a case series of 8 patients where anchor balloon technique was used to cannulate the CS due to inability to cannulate the CS despite using interventional techniques From 2017 to 2020, 8 patients were identified who required the anchor balloon technique for CS cannulation. Clinical information, imaging methods, LV lead implantation techniques, and complications were obtained by retrospective chart review. Stepwise description of using anchor balloon technique for CS cannulation is described in figure 1. The basic principle is to change the angle of approach and create a more supportive rail using compliant coronary balloons over which the sheath is advanced. Coronary balloons offer several advantages, they have a low profile, can track over wire, have a hydrophilic coating and can advance easily into CS. In our cohort of patients, anchor balloon technique was used to successfully cannulate the CS in all 8 patients where the other techniques had failed. In the group, 3 were denovo implants, 3 were upgrades to a prior implant and 2 were redo procedures where other operators had tried to implant the CS lead without success. 2 patients had prior history of open-heart surgery. The details of the patient population in each group are delineated in Table 1. Potential complications from using anchor balloons include vein rupture and laceration leading to pericardial effusion, but these were not seen in our study despite most patients with no prior history of open-heart surgery. Anchor balloon technique when added to the basic interventional CRT tools contributes to successful LV lead implantation in patients with challenging CS anatomy without any significant additional risk.Tabled 1Baseline CharacteristicsPatient IDAge (years)SexPrior open heart surgeryType of implant177MYesRedo271MYesUpgrade346FNoUpgrade471FNoDenovo561MNoDenovo653FNoDenovo757MNoUpgrade857FNoRedo Open table in a new tab

The Challenges of Cardiac Resynchronization Therapy in Patients with Dilated Cardiomyopathy and Persistent Left Superior Vena Cava: A Case Report and Concise Literature Review

Heart failure with reduced ejection fraction (HFrEF) is a chronic and debilitating disease, which requires extensive diagnostic and treatment resources in order to achieve an acceptable quality of life for the patient. While optimal medical treatment remains at the core of the disease's management, interventional cardiology also plays a very important role. However, in very rare situations, interventionists might find cases especially challenging due to the presence of venous anomalies, such as persistent left superior vena cava (PLSVC), anomalies that may go undiscovered during the patient's lifetime until venous cannulation is necessary. While these types of malformations also pose challenges in regards to standard pacemaker implantation, cardiac resynchronization (CRT) devices pose several additional challenges due to the complexity of the device and the necessity of finding an optimal position for the coronary sinus (CS) lead. We present the case of a 55-year-old male patient with advanced heart failure due to dilated cardiomyopathy (DCM) and LBBB who was a candidate for CRT-D therapy, describing the investigations that led to the discovery of the PLSVC as well as the technique and results of the intervention, while comparing our case to similar cases found in recent literature.

Clinical predictors of incomplete coronary sinus lead removal during transvenous lead extraction in patients with cardiac resynchronization therapy

Reports of coronary sinus (CS) lead removal include small studies with short implant durations. Procedural outcomes for mature CS leads removed with long duration implantation are unavailable. The purpose of this study was to examine the safety, efficacy, and clinical predictors of incomplete CS lead removal by transvenous lead extraction (TLE) in a large long implant duration cardiac resynchronization therapy patient cohort. Consecutive patients with cardiac resynchronization therapy devices in the Cleveland Clinic Prospective TLE Registry who had TLE between 2013 and 2022 were included in the analysis. CS leads (N = 231; implant duration 6.1 ± 4.0 years) removed from 226 patients were included, using powered sheaths for 137 leads (59.3%). Complete CS lead extraction success was achieved in 95.2% of leads (n = 220) and in 95.6% of patients (n = 216). Major complications occurred in 5 patients (2.2%). Patients who had the CS lead extracted first had significantly higher incomplete removal rates than when the other leads were first removed. Multivariable analysis showed that older CS lead age (odds ratio 1.35; 95% confidence interval 1.01-1.82; P = .03) and removal of the first CS lead (odds ratio 7.48; 95% confidence interval 1.02-54.95; P = .045) were independent predictors of incomplete CS lead removal. The complete and safe lead removal rate of long implant duration CS leads by TLE was 95%. However, CS lead age and the order in which leads were extracted were the independent predictors of incomplete CS lead removal. Therefore, before the CS lead is extracted, physicians should first extract the leads from the other chambers and use powered sheaths.

917 HYBRID TRANSVENOUS AND SURGICAL APPROACH FOR THE EXTRACTION OF CORONARY SINUS LEADS: A CASE SERIES

Abstract Background The rates of cardiac device-related infection have increased substantially over the past years. Transvenous lead extraction is the standard therapy for such cases. In some patients, however, the procedure cannot be completed through the transvenous route alone. A hybrid surgical and transvenous approach may provide the solution in such cases. Methods We present three cases who underwent hybird transvenous and surgical extraction for coronary sinus leads due to infection of CRT-D systems. One patient had an Attain Starfix lead implanted in the coronary sinus. The procedures were performed under local anaesthesia with continuous hemodynamic and transthoracic echocardiographic monitoring. We highlight the characteristics of the patients, the features of the devices, the technical difficulties and the outcomes of the procedures. Results In all cases, the right atrial and right ventricular leads were extracted through the transvenous route. In one patient, they were extracted using regular stylets and manual traction, while in the other two patients, telescoping dilator sheaths (Cook), Tightrail hand-powered mechanical sheaths (Spectranetics) and/or Glidelight Excimer Laser sheaths (Spectranetics) were used. The coronary sinus lead could not be retrieved due to extensive fibrosis after utilizing locking stylets and mechanical dilator sheaths in all 3 cases, in addition to rotational mechanical sheaths and Laser. sheaths in one case, so the so the patients were referred to surgery. Two patients underwent left mini-thoracotomy and one patient underwent midline sternotomy to extract the remaining CS lead. The target vein was identified and ligated, then the fibrosis around the lead was dissected, this was followed by lead retrieval through the surgical incision. The patient who underwent sternotomy suffered from mediastinitis, which required reoperation and mediastinal lavage. There were no complications in the other two patients. All three patients were reimplanted with a new CRT-D device on the contralateral side after the resolution of infection. Conclusion A hybrid surgical and transvenous approach can be complementary in case the transvenous route alone fails to completely extract the coronary sinus lead. The transvenous approach can be used to free the proximal part of the lead, while the distal adhesions can be removed surgically, preferably though a limited thoracic incision.

489 A RARE CASE OF LEAD EXTRACTION

Abstract Aims Poor data exist about the leadless PM implantation through a bioprosthetic tricuspid valve. Bioprosthetic tricuspid valve has traditionally represented a relative contraindication to transvenous right ventricular pacing for possible tricuspid bioprosthetic valve damage and dysfunction. Therefore, epicardial pacing is usually preferred to transvenous right pacing through a bioprosthetic tricuspid valve for the deleterious effect of permanent pacing leads on tricuspid bioprosthetic valve function and regurgitation. Methods Our case focuses on a 62-year-old woman with mechanical mitral and biological tricuspid prosthesis due to rheumatic disease since 2007 and with a PM-DDDR for a postsurgical complete atrioventricular block. A lead was implanted in right atrium while another lead was implanted in the coronary sinus (CS) instead of in the right ventricle following the presence of a biological tricuspid prosthesis. In February 2022, she did a replacement of pacemaker (PM) generator to another hospital due to initial battery depletion. In March she described pain at the device pocket and consequent appearance of pocket infection. For this situation she was admitted to our cardiac department. A transesophageal echocardiography (TEE) was performed and showed normal biventricular size and function (LVEF 55%), normal function of valve prostheses and absence of vegetations both on the valves and atrial lead. Subsequently an angiography was performed and revealed little patency of the anonymous-caval-subclavian left axis. We made a diagnosis of pocket infection and decided to extract leads in March. We proceded through debridement of leads and removal of the PM generator. After placing Spectranetics (Philips) Lead Locking Device n.2 (LLD2) along the 2007 right atrial lead, we removed it through the use of a mechanical extractors (Cook 7-8.5 Fr). Then after placing Spectranetics (Philips)Lead Locking Device E (LLDE), the CS lead was completely removed through the use of a mechanical extractors (Cook 7-8.5 Fr) and specific delivery.The procedure was well tolerated and uneventful. Following the negative result of the post-extraction blood cultures, cultures of lead tips and pocket swab, together with the normalization of inflammation indices (WBC and CRP) and to the end of antibiotic therapy, we decided to reimplant the device.For the presence of valve prostheses and the patient's high infectious risk, we decided to implant a leadless PM. Results At the beginning of April we performed a leadless Micra AV PM implantation through 23-F Micra TPS delivery catheter across a tricuspid bioprosthetic valve in the right ventricular apex instead of the middle septum due to implantation difficulties for the concomitant presence of the bioprosthetic valve. The procedure was well tolerated and uneventful too. She was discharged after 72h in good conditions. Conclusions We present an unusual case of lead extraction for the second infection of the device pocket in a patient with mechanical mitral and biological tricuspid prostheses and a lead in coronary sinus for the presence of biological tricuspid prosthesis. Leadless PM implantation represents a new technology by eliminating the risks connected with the presence of the lead across the bioprosthetic valve.