Coronary Sinus Lead Research Articles

17.2 Cardiac resynchronization: Multicenter experience with a new coronary sinus lead

17.2 Cardiac resynchronization: Multicenter experience with a new coronary sinus lead

17.2 Cardiac resynchronization: Multicenter experience with a new coronary sinus lead

17.2 Cardiac resynchronization: Multicenter experience with a new coronary sinus lead

17.2 Cardiac resynchronization: Multicenter experience with a new coronary sinus lead

17.2 Cardiac resynchronization: Multicenter experience with a new coronary sinus lead

P382 Comparison of the atrial defibrillation threshold in patients with and without coronary sinus lead

P382 Comparison of the atrial defibrillation threshold in patients with and without coronary sinus lead

Importance of the coronary sinus lead position on the clinical benefit of biventricular pacing

Importance of the coronary sinus lead position on the clinical benefit of biventricular pacing

Elevations in ventricular pacing threshold with the use of the Y adaptor: implications for biventricular pacing.

Cardiac resynchronization therapy (CRT) is a new and promising therapeutic option for patients with severe heart failure and intraventricular conduction delay. Patients who are candidates for CRT and have a previously implanted device may utilize a "Y" IS 1 connector to accommodate the coronary sinus lead. This modification has the potential to alter biventricular pacing thresholds. During an 18 month period, successful biventricular pacemaker implantation was performed in 72 patients (age: 67 +/- 11 years, left ventricular ejection fraction: 20.5 +/- 5.6%). All of these patients had severe symptomatic congestive heart failure (NYHA Class III and IV). In 20 patients a special "Y" adaptor that bifurcates the ventricular IS 1 bipolar output to two bipolar outputs or one unipolar and one bipolar output was utilized. During initial implantation, LV thresholds obtained in a unipolar configuration prior to connecting to the "Y" adaptor were significantly lower than thresholds obtained after connecting to the "Y" adaptor (1.7 +/- 1.11 V at 0.5 ms pulse width versus 2.8 +/- 1.5 V at 0.5 ms pulse width [P = 0.01]). Two patients (10%) required left ventricular lead revisions due to unacceptably high left ventricular thresholds during device follow-up. The difference in measured left ventricular thresholds between the two configurations is best explained by a resistive element that is added to the circuit when performing threshold measurement of the LV lead through the "Y" adaptor (combined tip to RV ring configuration) versus measurement of the LV lead in a unipolar configuration. This resistive element represents multiple factors including anode surface area, resistive polarization at the tissue-electrode interface, and transmyocardial resistance. LV thresholds should be measured in an LV tip to RV ring configuration or ideally in a combined tip (LV and RV) to shared ring configuration in order to accurately assess LV thresholds. This observation has significant clinical implications as loss of capture may occur as a result of improper measurement of left ventricular thresholds at the time of implantation.

P1525 Two years follow-up performance of a unipolar coronary sinus lead for left-ventricular pacing

P1525 Two years follow-up performance of a unipolar coronary sinus lead for left-ventricular pacing

Coronary sinus lead extraction.

Complications are reported more frequently with the implantation of coronary sinus (CS) than other types of leads, and attempts to extract CS leads may also be associated with increased risks. The authors have performed nonthoracotomy lead extraction (LE) since 1981 and maintained a detailed database. By November 2001, 796 leads had been removed from 401 patients. We undertook review of our CS-LE experience to evaluate prevalence, safety, and efficacy. Of 14 patients referred for CS-LE, 7 were treated in the last year. In six the lead had been placed in the CS intentionally, and in eight inadvertently. One recent patient treated with biventricular pacing was septic and died before LE was undertaken. In nine men and four women (mean age 66 years) had one each CS lead and a total of 34 LEs (2.6/patient). Four CS leads had been in place for < 6 months (mean 1.5 month), whereas nine had been in place for between 6 months and 27 years. Several LE methods were used, from simple traction to the use of intraluminal locking stylets and powered sheaths. Complete removal of all leads was achieved in all patients. CS-LE required a mean of 13 minutes, including 1.8 minutes of fluoroscopy. There were no serious complications during the procedures, and the mean hospital stay was 4 days.

Effect of left ventricular function on long-term left ventricular pacing and sensing threshold.

The effect of left ventricular (LV) systolic function on the long-term left ventricular pacing and sensing threshold is unclear. We studied the effect of LV ejection fraction (LVEF) on the LV pacing and sensing threshold in 56 patients (mean age: 70.2 +/- 10.5 years) underwent permanent LV pacing using a self-retaining coronary sinus lead (Model 1055 K, St Jude Medical, USA). In 49 patients, the LV lead was implanted for conventional pacemaker indication (sick sinus syndrome = 14, heart block = 26 or slow atrial fibrillation = 9). The remaining 7 patients were implanted for congestive heart failure. The LV pacing and sensing threshold, and lead impedance were compared between patients with LVEF <40% (Group 1, n = 28) and LVEF >40% (Group 2, n = 28) during implant and at 3-month follow up. The LV pacing lead was successfully implanted in all patients without any lead dislodgement on follow-up. At implant, Group 1 patients had a significant lower R wave amplitude, but similar LV pacing threshold and lead impedance as compared to Group 2. However, at 3-month follow-up, Group 1 patients had a significantly higher LV pacing threshold compared to Group 2 patients. There were no significant differences in the sensing threshold and lead impedance between the two groups. Furthermore, there was also a significant interval increase in LV pacing threshold in Group 1 patients (0.94 +/- 0.12 V) after 3 months, but not in Group 2 patients (0.16 +/- 0.08 V, p < 0.01). The results of this study suggest that the LV systolic function has a significant impact on the long-term LV pacing threshold. The long-term left ventricular pacing threshold in patients with left ventricular systolic dysfunction increased after implant and was higher than patients with normal left ventricular systolic function.

Dislodgment of the lead in coronary sinus for left ventricular pacing: Is this event predictable on the basis of any parameters evaluable at implant?

Dislodgment of the lead in coronary sinus for left ventricular pacing: Is this event predictable on the basis of any parameters evaluable at implant?

Dislodgment of the lead in coronary sinus for left ventricular pacing: Is this event predictable on the basis of any parameters evaluable at implant?

Dislodgment of the lead in coronary sinus for left ventricular pacing: Is this event predictable on the basis of any parameters evaluable at implant?

Evaluation of a new triple chamber implantable cardioverter defibrillator and a new over‐the‐wire coronary sinus lead in the treatment of heart failure

Evaluation of a new triple chamber implantable cardioverter defibrillator and a new over‐the‐wire coronary sinus lead in the treatment of heart failure

Permanent left atrial pacing with a specifically designed coronary sinus lead.

This article reports the original use of a specifically designed coronary sinus (CS) lead for permanent left atrial (LA) pacing. The device is characterized by its distal end shape featuring a double 45 degree angulation, which ensures very close contact with the CS upper wall. The device was successfully implanted in 39 out of 40 patients (97.5%). The tip electrode was eventually positioned in the distal CS in 9 patients, in the middle CS in 21 patients, and close to the ostium in the proximal CS in 9 patients. The mean acute pacing threshold voltage was 0.9 +/- 0.5 V with a mean impedance of 578 +/- 144 omega as measured in unipolar distal configuration at 0.5 ms pulse width (PW). The mean A wave amplitude was 3.5 +/- 2.1 mV. Early lead dislodgment occurred only once (3%) when the tip electrode was placed in the distal or middle CS, but more often (4/9 cases) when it was placed in the proximal CS. After a mean follow-up duration of 14 +/- 8.5 months, 35 of the 39 successfully implanted leads (89.7%) were still functional in terms of LA pacing and sensing. The mean chronic pacing threshold voltage was 1.5 +/- 0.8 V and the mean A wave amplitude was 2.7 +/- 1.6 mV. There were no lead related complications. In conclusion, the device proved to be safe and highly effective for permanent LA pacing, provided the distal tip could be positioned in the distal or middle part of the CS.

Anatomical Findings in Patients Having Had a Chronically Indwelling Coronary Sinus Defibrillation Lead

The purpose of this report is to review the gross and histological cardiac anatomical findings in patients with chronically indwelling coronary sinus leads at the time of autopsy or cardiac transplantation. Transvenous cardioverter defibrillators offer effective protection against sudden death. The use of a coronary sinus electrode has been shown in some patients to decrease the defibrillation threshold. The anatomical consequences of chronically indwelling coronary sinus cardioversion/defibrillation electrodes in patients having transvenous implantable cardioverter defibrillators is unknown. The hearts of seven patients with chronically indwelling coronary sinus electrodes were evaluated following autopsy (n = 2) or cardiac transplantation (n = 5). The coronary sinus electrode in each case was a 6.5 French silicone lead with a 5-cm long defibrillation coil (Medtronic CS lead model 6933) that was positioned as distally as possible within the coronary sinus at the time of implantable cardioverter defibrillator surgery. The seven hearts examined were derived from patients whose age ranged between 49 and 69 (mean 56 +/- 7 years). Six had coronary artery disease and one had idiopathic dilated cardiomyopathy. The time from implant to death or cardiac transplantation was 8 +/- 6 months, range 1-18 months. In all seven patients, there was no evidence of any significant damage from the presence of the coronary sinus lead. The only finding in each case was the scattered presence of a thin white fibrous sheath over the lead that intermittently adhered to the coronary sinus endothelium and, in the two patients transplanted 1-3 months after implantable cardioverter defibrillator insertion, a mild inflammation reaction adjacent to the leads in the coronary sinus endothelium. There was no evidence of coronary sinus occlusion, adjacent coronary artery injury, coronary sinus perforation, coronary sinus burn, or myocardial injury adjacent to the lead. Cause of death was due to end-stage congestive heart failure and thrombotic stroke, respectively, in the two patients examined at autopsy. Coronary sinus defibrillation leads can be used safely without harmful anatomical effect.

911-34 Comparison of Pulmonary Artery vs. Coronary Sinus Lead Position for Low Energy Conversion of Atrial Fibrillation

Animal studies show that low energy intracardiac conversion (IC) of atrial fibrillation (AF) is feasible. A lead position in the distal coronary sinus (CS) vs. right atrium (RA) showed lower energy levels for conversion than left pulmonary artery (PA) vs. RA. Cardioversion was attempted in 25 patients (pts), 15 randomized to the CS/RA lead position and 10 to PNRA. The CS group consisted of 4 females, mean age at 60.2 ± 8.2 years, left atrial diameters ranged from 54 to 71 mm with a mean of 59.2 ± 4.9 mm, AF duration was 9.5 ± 9.0 months (range 1 – 36 months). The PA group consisted of 3 females, mean age 60.5 ± 10.5 years, left atrial diameters ranged from 54 to 76 mm with a mean of 64.5 ± 6.6 mm, AF duration was 13.7 ± 22 months (0.5 – 79 months). There were no significant differences between the two groups. Biphasic shocks (3 ms ± 2 ms) were R-wave triggered and delivered in increments of 40 V from an external defibrillator (Ventritex HVS 02, Sunnyvale, CA) via two custom made catheters (6 F, Elecath Inc., Rahway, NJ) to a maximum energy of 11.1 J or successful conversion to sinus rhythm. Pts were sedated with midazolam. In the CS group conversion in 13/15 pts was achieved at a mean energy level of 3.7 ± 1.6 J, range 1.0 – 6.6 J. Mean lead impedance was 58.8 ± 7.5 Ω. In the PA group, IC was successful in 9/10 pts, the mean energy level was 4.4 ± 2.1 J, range 2.5 – 11.1 J. Mean lead impedance was 59.1 ± 10.0 Ω. No severe complications were observed in either lead position group. There was no significant difference between CS and PA. Low energy biphasic shocks delivered between RA and CS or PA are successful in conversion of AF. Positioning of the anodal electrode in the PA shows slightly higher thresholds and lead impedances than the CS position. From a practical point of view, however, the pulmonary electrode is advantageous for positioning a single balloon guided catheter with electrodes in PA and RA position; this is currently under development.

Early postoperative increase in defibrillation threshold with nonthoracotomy system in humans.

The stability of the defibrillation threshold (DFT) early after implantation of an implantable cardioverter defibrillator was evaluated in 15 patients. All but one patient had a three lead nonthoracotomy system using a subcutaneous patch, a right ventricular endocardial lead, and a lead in coronary sinus (n = 5) or superior vena cava (n = 9). Shocks were delivered using simultaneous in nine, sequential in three, and single pathway (coronary sinus not used) in one patient. DFTs were measured at implant (n = 15), 2-8 days postoperation (postop, n = 15), and 4-6 weeks later (n = 8). The DFT was defined as the lowest energy shock that resulted in successful defibrillation. The DFT was assessed with output beginning at 18 joules or 2-4 joules above the implant DFT. All shocks were delivered in 2- to 4-joule increments or decrements. DFTs were significantly higher postoperatively than DFTs at implant (22.7 +/- 7.0 J vs 16.9 +/- 3.9 J; P < 0.05). Eight of 15 patients had DFT determined at all three study periods. In these patients, DFT increased at postop (22.8 +/- 8.3 J vs 16.4 +/- 3.9 J at implant; P < 0.05) and returned to baseline at 4-6 weeks (16 +/- 7.1 J vs 16.4 +/- 3.9 J at implant; P = N.S.). Thus, in patients with a multilead nonthoracotomy system, a DFT rise was observed early after implant. The DFT appears to return to baseline in 4-6 weeks. These results have important implications for programming energy output after implantable cardioverter defibrillator implantation.

Efficacy of a single-lead unipolar transvenous defibrillator compared with a system employing an additional coronary sinus electrode. A prospective, randomized study.

Recent development of a prototype single-lead unipolar transvenous defibrillator offers the possibility of device implantation with the ease of a permanent pacemaker. Lowering defibrillation energy requirements would allow for a further reduction in defibrillator generator size and enhance the feasibility of pacemaker-like placement. However, if achieving a lower defibrillation energy requires placing additional intracardiac leads, the potential advantage of a smaller generator may be offset by the disadvantages of a more complex lead system. The purpose of this study was to compare defibrillation energy requirements of a single-lead unipolar defibrillator with a three-electrode system employing an additional lead in the coronary sinus. Testing of a single-lead unipolar biphasic pulse defibrillation system versus a three-electrode system with an additional coronary sinus lead was performed in prospective, randomized fashion in 15 patients with a history of ventricular tachycardia or fibrillation. Ventricular fibrillation was induced with alternating current, and defibrillation threshold was measured by a pulse given 10 seconds after arrhythmia induction. The mean defibrillation threshold stored energy and mean leading edge voltage did not significantly differ between the two systems (11.3 +/- 5.9 J versus 9.9 +/- 5.2 J and 418 +/- 118 V versus 390 +/- 112 V, respectively; P > .4). Using either defibrillation system, all patients were successfully defibrillated by < 24 J and over half of patients by < 10 J. A unipolar transvenous biphasic defibrillation system is an effective means of treating ventricular fibrillation. The added complexity of additional leads is not offset by any significant improvement in defibrillation efficacy or energy requirements. Given the simplicity and effectiveness of a single-lead system coupled with a small generator, placement of defibrillation systems may now approach the ease of pacemaker implantation.

Bipolar coronary sinus lead for left atrial and left ventricular recording

T he use of transvenous pacing catheters is not without potential complications and problems. One of these, associated with a high incidence of failure to pace, is inadvertent passage of the catheter through the coronary sinus into a coronary veL1x2 The use of a routine posteroanterior chest x-ray film to diagnose this complication is often unreliable.2 A superior location of the catheter tip between the left atrium and the posterobasal (or lateral) aspect of the left ventricle suggests passage into the great cardiac vein or beyond.3 However, passage into the middle cardiac vein is more difficult to diagnose with a posteroanterior film, although a lateral view will demonstrate the posterior location of the tip.2 Electrocardiographic diagnosis of malposition may be of some help. For instance, the mean QRS vector of paced ventricular beats when the catheter tip is in the great cardiac vein is inferiorly directed and associated with a right bundle branch block (RBBB) pattern due to delayed activation of the right ventricle,4 while a middle cardiac vein location is indicated by left axis duration (due to inferior site of stimulation) and a RBBB pattern (due to the posterior location of the electrodes) .2 Despite the fact that great cardiac vein catheterization is a troublesome complication for purposes of pacing, the intentional use of this technique for studies of human cardiac electrophysiology may prove to be quite useful. We are currently evaluating the use of coronary sinus and His bundle electrograms in analyzing the activation process of the human heart.