Lead Insertion Research Articles

Post Dural Puncture Headache After Spinal Cord Stimulator Lead Insertion Successfully Treated with Occipital Nerve Blocks

Post Dural Puncture Headache After Spinal Cord Stimulator Lead Insertion Successfully Treated with Occipital Nerve Blocks

Measurements of the Neutron Field Parameters with Monitors based on the Gas-Filled Proportional Counters

Neutron monitors with the gas filled proportional counters inside and first data were presented at RuPAC-2018 and RuPAC-2021 conferences. It is planned to use such devices to monitor the stability of irradiation conditions during radiation therapy sessions. We present here the calibration procedure for these monitors at AmBe neutron source, and the new data. These monitors have been used to measure the neutron fluence behind the shielding of the 450 MeV/nucleon carbon beam based experimental facility “Shared use Center – radiobiological stand with the carbon beam of the U-70 accelerator at IHEP”. The measurements were supported by the set of extensive simulations using the CERN FLUKA code. Good agreement between the FLUKA simulations and measurements was shown. Even single monitor with lead insertion calibrated at AmBe neutron source allows to have a good result in the real neutron field. The possibility to estimate the fluence of the high energy neutrons with the energy above 10 MeV using data from the pair of monitors was demonstrated. To improve the quality of the measurements one needs to take into account difference between calibration and measurements conditions.

Fracture risk analysis of a stylet-driven lead for left bundle branch area pacing using a human beating heart model

Abstract Background Left bundle branch area pacing (LBBAP) has emerged as a promising approach to cardiac physiologic pacing. However, the mechanical stress and fracture risk has not been studied for stylet-driven leads implanted in the left bundle branch area (LBBA). Purpose The main purpose of this study was to evaluate the change in curvature during a cardiac cycle when a stylet-driven lead with a rigid distal end was implanted in LBBA and to identify any increased risk of conductor fracture for the LBBAP lead compared to those implanted at the His bundle (HB), traditional right atrium (RA) and right ventricle (RV) locations. Methods A high-resolution, four-dimensional human beating heart model was utilized for simulating the stress on the lead. The bending stiffness of lead body segments was measured with 3-pts bending test and the values were assigned to the finite element model. The curvature change of lead body during one cardiac cycle was measured. The safety factor of lead conductors was calculated using the curvature measurements, the conductor’s endurance limit, and the ultimate stress of the material (MP35N). A higher safety factor indicates better lead durability and lower risk of fracture. A parametric study was also performed to investigate how additional implant factors impact the safety factor of LBBAP leads: lead insertion angle, implant depth, degree of slack, and implant location (Figure 1). Results A total of 8 implant scenarios for LBBAP were defined and tested using the combination of the implant factors described above. Two RV implanted locations were tested: RV apex and RV apical septum. One HBP and one RA implant location were tested. The region with maximum change in curvature for LBBAP lead was at 0-10 mm proximal to the ring electrode (Figure 2A). The maximum change in curvature on the lead body for LBBAP, HBP, RV, and RA implants were: 0.022±0.005 (n=8), 0.033 (n=1), 0.036±0.002 (n=2), and 0.024 mm-1 (n=1), respectively (Figure 2B). The safety factor for the lead conductors for LBBAP, HBP, RV, and RA implants were 5.57±1.35 (n=8), 3.48 (n=1), 4.62±0.04 (n=2), and 4.65 (n=1), respectively (Figure 2C). The highest safety factor among all implant locations was 7.63, corresponding to a LBBAP implant scenario with mid-septum location, a 45 degree lead insertion angle towards apex, 7.5 mm lead depth in the septum, and low lead slack. HBP had the lowest safety factor among all implant locations. Conclusion The stylet-driven lead with a rigid distal end implanted at the left bundle branch area does not introduce any further risk of fracture compared to the HBP or traditional RA/RV implant locations in this computational modeling study.Fig 1: LBBAP implants testedFig 2: Lead curvature and safety factor

When and how to perform venoplasty for lead placement

Because of the increasing use of cardiac implantable electronic devices (CIEDs) with one or more intracardiac electrodes, the rate of lead failure is increasing. Moreover, upgrade of the CIED frequently is indicated for cardiac resynchronization therapy or other reasons. Both these situations require a new intervention, preferably using ipsilateral venous access. However, venous obstruction after CIED insertion occurs in 10%–20% of patients and poses a major obstacle for implantation of additional leads. Possible solutions include lead extraction, contralateral lead insertion, and venoplasty. Preprocedural venoplasty is associated with the lowest short- and long-term risks. Here we describe a step-by-step approach to this technique, which can be introduced and safely performed in most interventional catheterization laboratories.

Connectomic deep brain stimulators in Parkinson`s sub cortical functional zones

Shaking palsy is a brain disease involving motor and non motor zones affecting circa 1 to 2%of humans>60 years age. To date there has been no invention for curing this chronic disease and to stop its progression. But existing therapeutic procedures can offer symptomatic relief to Parkinson patients. DBS is most successful therapy for the Parkinson`s yet depends on the accuracy of electrode implantation and location within the anatomical subcortical neural-structures. This study examines the likelihood of net-work-based induced stimuli and the application of connectomic DBS in Parkinson`s. The subthalamic nucleus is divided into3 sub zones, namely, limbic (anterior), associative (middle) and motor (posterior) as well as diffusion weighted imaging (D W I). The surgical targets are tiny (few millimeters) and good enough to neuroanatomical-structures within the b r a i n. STN (size:12×5×3mm3) and lies nearby internal capsule, medial lemniscus, corticospinal tract, plus red-nucleus. Through sub optimal lead insertion and over stimuli, flow of electrons can spread to these adjoining sucortics, thereby developing dyskinesias ( ). With time, DW-MRI plus f-MRI is used to study the anatomical-structural functional connectivity in advanced idiopathic Parkinson`s. Contrasting conventional lesion based stimulus hypothesis, the novel net stimulus hypothesis advocated that induced stimulus of exact circuits of b r a i n can modulate pathophysiological net-work, reinstate near the tissue region, thus producing stabilization-of human-brain-connectome within Parkinson`s. The DBS connectomes makes use of circuit based stimulus procedure instead of lesion-based stimulus, has transformed neuromodulation. Connectomes via DBS can be tailor made for every Parkinson plus enhance the operation. It`s just a sketch for human-brain-connectivity (HMC) transversely compound longitudinal-scales. Yet, it won`t yield cell information plus cotacts with cells at the level of micro scale.

Clinical evaluation of a stereotactic system for single-stage deep brain stimulation surgery under general anesthesia: technical note.

Conventional frame-based stereotactic systems have circumferential base frames, often necessitating deep brain stimulation (DBS) surgery in two stages: intracranial electrode insertion followed by surgical re-preparation and pulse generator implantation. Some patients do not tolerate awake surgery, underscoring the need for a safe alternative for asleep DBS surgery. A frame-based stereotactic system with a skull-mounted "key" in lieu of a circumferential base frame received US FDA clearance. The authors describe the system's application for single-stage, asleep DBS surgery in 8 patients at their institution and review its workflow and technical considerations. Eight patients underwent DBS lead insertion and IPG implantation in a single surgical preparation under general anesthesia using the system. Postoperative CT imaging confirmed lead placement. Eight patients underwent implantation of 15 total leads targeting the ventral intermediate nucleus (4 patients), globus pallidus internus (GPi; 3 patients), and subthalamic nucleus (STN; 1 patient). Intraoperative microelectrode recording was conducted for GPi and STN targets. Postoperative CT imaging revealed a mean ± SD radial error of 1.24 ± 0.45 mm (n = 15 leads), without surgical complications. The stereotactic system facilitated safe and effective asleep, single-stage DBS surgery, maintaining traditional lead accuracy standards.

Caudal fluoroscopic guidance for the insertion of transvenous pacing leads.

Pneumothorax is a well-recognized complication of cardiac implantable electronic device (CIED) insertion. While AP fluoroscopy alone is the most commonly imaging technique for subclavian or axillary access, caudal fluoroscopy (angle 40°) is routinely used at our institution. The caudal view provides additional separation of the first rib and clavicle and may reduce the risk of pneumothorax. We assessed outcomes at our institution of AP and caudal fluoroscopic guided pacing lead insertion. Retrospective cohort study of consecutive patients undergoing transvenous lead insertion for pacemakers, defibrillators, and cardiac resynchronization therapy devices between 2011 and 2023. Both de novo and lead replacement/upgrade procedures were included. Data were extracted from operative, radiology, and discharge reports. All patients underwent postprocedure chest radiography. Three thousand two hundred fifty-two patients underwent insertion of pacing leads between February 2011 and March 2023. Mean age was 71.1 years (range 16-102) and 66.7% were male. Most (n = 2536; 78.0%) procedures used caudal guidance to obtain venous access, while 716 (22.0%) procedures used AP guidance alone. Pneumothoraxes occurred in five (0.2%) patients in the caudal group and five (0.7%) patients in the AP group (p = .03). Subclavian contrast venography was performed less frequently in the caudal group (26.2% vs. 42.7%, p < .01). Caudal fluoroscopy for axillary/subclavian access is associated with a lower rate of pneumothorax and contrast venography compared with an AP approach.

New-generation Leadless Pacemaker Implantation: First Procedures in Central Asia.

In this article, we describe our first experiences implanting the AVEIR VR leadless pacemaker (Abbott) in Kazakhstani patients, a significant step in the development of this technology in Central Asia. This case series includes five male patients, with a range of symptoms (presyncope, dizziness and dyspnoea on exertion), ranging in age from 14 to 77 years; some individuals also had comorbidities, including atrioventricular block and AF. Indications for pacing were identified in each patient. The parameters of postimplantation stimulation and the results of initial observations were recorded. The procedure was quite successful and radiographic confirmation of the location of the leadless pacemaker was obtained. All patients demonstrated clinical improvement and satisfactory pacing parameters at early follow-up. The potential of the AVEIR leadless pacemaker to minimise lead insertion complications has been demonstrated, with no immediate complications observed in the patients in this study.

Pacemaker lead insertion sites contribute to abnormalities of myocardial function and histopathology

Ventricular pacing can cause myocardial dysfunction, but how lead anchoring to the myocardium affects function has not been studied. The purpose of this study was to evaluate patterns of regional and global ventricular function in patients with a ventricular lead using cine cardiac computed tomography (CCT) and histology. This was a single-center retrospective study with 2 groups of patients with a ventricular lead: (1) those who underwent cine CCT from September 2020 to June 2021 and (2) those whose cardiac specimen was analyzed histologically. Regional wall motion abnormalities on CCT were assessed in relation to lead characteristics. For the CCT group, 122 ventricular lead insertion sites were analyzed in 43 patients (47% female; median age 19 years; range 3-57 years). Regional wall motion abnormalities were present at 51 of 122 lead insertion sites (42%) in 23 of 43 patients (53%). The prevalence of a lead insertion-associated regional wall motion abnormality was higher with active pacing (55% vs 18%; P < .001). Patients with lead insertion-associated regional wall motion abnormalities had a lower systemic ventricular ejection fraction (median 38% vs 53%; P < .001) than did those without regional wall motion abnormalities. For the histology group, 3 patients with 10 epicardial lead insertion sites were studied. Myocardial compression, fibrosis, and calcifications were commonly present directly under active leads. Lead insertion site-associated regional wall motion abnormalities are common and associated with systemic ventricular dysfunction. Histopathological alterations including myocardial compression, fibrosis, and calcifications beneath active leads may explain this finding.

The contralateral oblique fluoroscopic view is associated with a lower incidence of postdural puncture headache in patients undergoing percutaneous spinal cord stimulation.

Spinal cord stimulation (SCS) is a minimally invasive therapy that is increasingly used to treat refractory neuropathic pain. Although this technique has a low incidence of serious long-term adverse sequelae, the risk of complications such as inadvertent dural puncture remains. The goal of this article was to determine the impact of the contralateral oblique (CLO) fluoroscopic view incidence of postdural puncture headache (PDPH) during spinal cord stimulator implantation as compared to lateral fluoroscopic view. This was a single academic institution retrospective analysis of electronic medical records spanning an approximate 20-year time period. Operative and postoperative notes were reviewed for details on dural puncture, including technique and spinal level of access, the development of a PDPH, and subsequent management. Over nearly two decades, a total of 1637 leads inserted resulted in 5 PDPH that were refractory to conservative measures but responded to epidural blood patch without long-term complications. The incidence of PDPH per lead insertion utilizing loss of resistance and lateral fluoroscopic guidance was 0.8% (4/489). However, adoption of CLO guidance was associated with a lower rate of PDPH at 0.08% (1/1148), p < 0.02. The incorporation of the CLO view to guide epidural needle placement can decrease the odds of a PDPH during percutaneous SCS procedures. This study further provides real-world data supporting the potential enhanced accuracy of epidural needle placement in order to avoid unintentional puncture or trauma to deeper spinal anatomic structures.

Synthesis and characterization of lead metallated non-peripherally substituted octa-octyl tetrabenzo(aza)porphyrins showing face-to-face columnar stacking in the crystal phase

The full range of porphyrin-phthalocyanine hybrids can be synthesized by treatment of 1,4-dioctylphthalonitrile with varying equivalents of MeMgBr to produce mixtures favoring specific hybrid structures and the tetrabenzoporphyrin in the extreme case. The individual macrocycles can be isolated in pure form as their magnesium derivatives and subsequently demetallated to give the parent metal-free compounds. Insertion of lead proceeded smoothly with all hybrids using lead (II) acetate. In the case of monoaza- and triaza-hybrids, the resulting materials could be recrystallized to give crystals suitable for X-ray diffraction. The crystal structures are distinctive from previously reported examples of non-peripherally substituted octaalkyl phthalocyanines and hybrids (metal-free and metallated, including with lead) and they each present infinite stacks of cofacial macrocycles linked through bridging lead ions which, as expected, lie outside of the macrocycle plane.

Acute pericarditis complicating transcatheter mitral valve repair: A case report

Post-cardiac injury syndrome may occur after acute myocardial infarction, cardiac surgery or percutaneous cardiac interventions, such as percutaneous coronary angioplasty, pacemaker lead insertion and post-ablation procedures. In this case report, we describe the case of an 80-year-old female patient

ID: 213146 Trends in Medicare Reimbursement for Deep Brain Stimulation Surgery: 2004-2021

The viability of multidisciplinary movement disorder programs depends heavily on reimbursement for Deep Brain Stimulation (DBS) surgery. Procedures related to DBS include cranial lead insertion, generator placement, microelectrode recording, as well as lead or generator replacements or revisions. These procedures are tied to Current Procedural Terminology (CPT) codes with associated reimbursement rates maintained by the Centers for Medicare and Medicaid Services (CMS). Though not the sole factor in what is ultimately reimbursed to a facility, annual differences in pricing associated with CPT coding can reflect relative changes to reimbursement rates. The purpose of this study was to evaluate trends in Medicare reimbursement for DBS surgery from 2004-2021 when corrected for inflation.

PO-04-013 A CASE OF INTERMITTENT ANODAL CAPTURE AFTER LEFT BUNDLE AREA PACING

Left bundle area pacing (LBAP) is emerging as a reliable form of conduction system pacing (CSP) that can be beneficial in cardiac resynchronization therapy (CRT). We present a case of intermittent anodal capture noted after septal lead insertion in a patient undergoing LBAP. N/A An 80-year-old male with hypertension, COPD, and sick sinus syndrome who had undergone dual chamber pacemaker implantation in 2007, had known atrial lead fracture since 2020, now presented with heart failure syndrome (EF dropped from 60% to 15%). A coronary angiogram showed non-obstructive coronary artery disease. As such decision was made for fractured atrial lead extraction and implantation of new atrial lead to provide AV synchrony as well as upgrading the device to biventricular ICD, given the persistent low ejection fraction. During the procedure, coronary sinus anatomy was found unsuitable for lead insertion, and hence LBAP was opted for instead. LBAP lead was placed at an appropriate septal location with QRS morphology in lead V1 changing from an initial “W” pattern to notching as the lead was advanced with an appropriate rise in thresholds. QRS duration decreased to 144 milliseconds; however, intermittently variable QRS morphologies were noted. In LBAP, anodal capture can occur during bipolar configuration where the tip of the lead (cathode) is capturing the left bundle, and the ring (anode) starts capturing the right bundle area. This happens when the lead is penetrating the interventricular septum (IVS) enough for the ring portion to come into contact with the right septal area. In our patient, note the different QRS morphologies in lead V1 (Panel A). The right bundle morphology QRS (marked red) is the expected result of LB pacing, while the left bundle morphology QRS (marked green) is likely occurring from concurrent anodal capture of the right bundle. The QRS duration is noted to be somewhat narrower when the left bundle morphology is present, as would be expected when both bundles are simultaneously captured (LB by the tip and RB by the ring) (Panel B). It is unclear whether such a phenomenon as anodal capture of the RB along with concurrent LB pacing can be of any clinical significance and needs further research.

PO-03-009 3830 LEAD TIP POSITION ON COMPUTED TOMOGRAPHY AND ELECTROPHYSIOLOGIC OUTCOMES IN LEFT BUNDLE BRANCH AREA PACING

Prior studies have evaluated the impact of lead tip distance from the LV blood pool on pacing parameters during left bundle branch area pacing (LBBAP). Few studies to date have evaluated lead tip angulation within the interventricular septum (IVS) in relation to pacing morphology on surface 12-lead ECG. To establish the observed lead tip trajectories within the interventricular septum encountered during LBBAP. Patients who underwent LBBAP implantation between 02/2019-07/2022 were retrospectively analyzed. Patients who underwent computed tomography (CT) of the chest or thorax post-implantation for any indication were included for analysis. Lead distance from the mitral annulus, lead tip distance from LV blood pool (DEBP), lead tip angle of incidence (AOI), and post-implantation electrocardiographic and pacing parameters were analyzed (Figure 1a). 38 pts were identified, out of whom 37 pts had CT images available for analysis. In the 20 pts with contrast enhanced imaging, DEBP was 2.1±1.8mm. Average observed AOI was 10.9±20.6 degrees in the axial plane (long axis; Figure 1b) and 12.4±22.2 degrees in the saggital plane (short axis; Figure 1c). Lead impedance at time of implant did not correlate strongly with axial or sagittal angle of incidence (R2=0.01 and 0.03 respectively) or with distance from LV endocardial blood pool (R2=0.04). The most commonly encountered lead insertion locations included the mid-septal (22, 59.5%), basal septal (4, 10.8%), and mid antero-septal (3, 8.1%) positions (Figure 1d). Average lead tip distance from the AV annulus was 36.6±8.2mm. Mean paced QRSd for the basal, mid, and apical cohorts were 122.5±8.1ms, 118.5±10.7ms, and 120±15.9ms, respectively. Left ventricular activation time in lead V6 numerically decreased for more apical positions, with basal, mid and apical values of 84.4±11.9ms, 73.9±10.6ms, and 69.5±6.0ms, respectively. Lead threshold, impedance, and sensed R waves were stable at time of 2 year follow-up. No analyzed patients underwent lead revision. Multiple lead tip orientations are observed in relation to the IVS during successful LBBAP. More apical lead tip positioning may result in numerically lower LVAT values, despite similar overall QRS duration.

PO-04-068 STEREOTACTIC ARRHYTHMIA RADIOTHERAPY DOES NOT ALTER TECHNICAL IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR FUNCTION: DETAILED SAFETY RESULTS OF THE PROSPECTIVE STARNL-1 TRIAL

Stereotactic arrhythmia radiotherapy (STAR) is a new potential treatment for patients with therapy-refractory ventricular tachycardia (VT). During STAR, the pro-arrhythmic substrate receives high-dose irradiation in a single fraction. Inherently, part of the implantable cardioverter-defibrillator (ICD) lead tips, leads and the site of lead insertion receive radiotherapy dose as well. This may directly, or indirectly due to induced fibrosis at the site of lead insertion, affect technical ICD functioning. To evaluate the effects of STAR on technical ICD functioning. The STARNL-1 was a prospective, single arm, pre-post intervention study. Patients with recurrent VT despite high doses of anti-arrhythmic drugs and after one or more catheter ablation(s) were considered therapy-refractory. Six patients were treated with a single radiotherapy dose of 25 Gy to the pro-arrhythmic substrate. Per protocol, ICD battery longevity and ICD parameters lead impedance, lead sense, and lead capture of the atrial/ventricular leads were collected from ICD readouts pre-therapy, within the first 24 hours after therapy and at 3 and 12 months after therapy. During targeting, the ICD generator was considered an organ at risk. The ICD leads and lead tips were not taken into account, therefore the ICD lead tips were retrospectively delineated to calculate the received radiotherapy dose. Since this study was not powered for statistical comparison of ICD parameters, ICD parameters were described. All six patients were male (age 54-83 years) and suffered from ischemic cardiomyopathy (left ventricular ejection fraction 24-52%). Four patients completed 12-month follow-up. Five patients had a dual-chamber ICD and one patient had a single-chamber ICD. The ICD generator received a median radiotherapy dose of 0.01 Gy (range 0.00-0.12 Gy), the atrial lead a median radiotherapy dose of 3.9 Gy (range 0.7-7.2 Gy), and the ventricular lead a median radiotherapy dose of 16.8 Gy (range 0.2-24.7 Gy). There was no sudden drop in battery longevity during follow-up. As can be appreciated from Table 1, atrial and ventricular lead impedance, sensing and capture were not altered during 12-month follow-up. Figure 1 shows a line graph of the ventricular lead impedance. STAR for VT does not alter technical ICD functioning within the first 12 months after treatment.Tabled 1ICD parameter results.ICD parameterPre-therapyWithin 24h after therapy3m12mAtrial lead impedance, Ohm419 (330-550)419 (310-550)433 (340-490)404 (390-440)Atrial lead sensing, mV1.8 (0.6-5.0)3.3 (0.9-5.0)2.0 (0.5-5.0)1.6 (0.6-5.0)Atrial lead capture, V0.69 (0.38-1.00)0.56 (0.50-1.00)0.56 (0.38-1.00)0.56 (0.38-0.75)Ventricular lead impedance, Ohm499 (390-766)465 (350-867)455 (360-838)460 (390-737)Ventricular lead sensing, mV12.0 (7.2-19.4)12.0 (11.7-20.1)12.0 (4.4-20.3)11.9 (11.7-19.9)Ventricular lead capture, V1.00 (0.63-3.50)0.88 (0.63-3.50)1.00 (0.63-3.88)0.88 (0.50-2.50)All parameters are provided as median (range). Open table in a new tab

154 Comparison of Chronic and Intraoperative LFP and ECoG Recordings in Humans With Parkinson’s Disease

INTRODUCTION: Advances in implantable neurotechnologies have enabled chronic invasive long-term recordings of field potentials from depth leads or paddle-type electrocorticography (ECoG) leads. The relationship between these long-term recordings and those obtained acutely in the operating room has not been studied. METHODS: Human subjects (n=6) with movement disorders (Parkinson’s disease, dystonia) were permanently implanted with quadripolar DBS leads, and quadripolar ECoG leads over primary motor and sensory cortices, attached to a Medtronic Summit RC+S investigational device in the chest. Recordings were acquired intraoperatively using a NeuroOmega (Alpha Omega, Inc) recording system customized for research use. RC+S recordings were acquired between 1 and 345 days post implantation. The same processing pipeline was applied to both data sets, and average power spectra in canonical frequency bands (delta, theta, alpha, beta, gamma) were compared using rank sum tests within each subject. RESULTS: Power spectra show similar power law scaling phenomena between intraoperative and chronic recordings. Disease specific frequency band characteristics such as beta peaks could be seen in both chronic and intraoperative recordings, however, within subjects these were not always consistently seen. CONCLUSIONS: We present within-patient comparisons of signal characteristics (power spectra) of intraoperative recordings from a research grade recording system, with wirelessly streamed data from a chronic implantable device, using the same brain leads. Power spectra have similar characteristics between the intraoperative and long term recordings, however, there are distinct differences between the intraoperative and longer term clinic recordings, reinforcing the utility of tracking neural signals over time after the effects of lead insertion on the motor circuit have diminished.

Left Bundle Branch Pacing for Bradycardia in Non-obstructive Hypertrophic Cardiomyopathy Patients: Feasibility, Safety, and Effect.

Left bundle branch pacing (LBBP) is as an innovative physiological pacing approach. The research on LBBP in non-obstructive hypertrophic cardiomyopathy (NOHCM) patients is scarce. This study aimed to assess the feasibility, safety, and effect of LBBP in bradycardia NOHCM patients with permanent pacemaker (PPM) implantation indication. Thirteen consecutive patients with NOHCM who received LBBP were retrospectively enrolled as a hypertrophic cardiomyopathy (HCM) group. Following 1:3 matching, 39 patients without HCM were randomly matched as a control group. Echocardiographic index and pacing parameters were collected. The successful LBBP was achieved in 96.2% of all cases (50/52), and the success rate of the HCM group was 92.3% (12/13). In the HCM group, the paced QRS duration (from the pacing stimulus to QRS end) was 145.6±20.8 ms. The stimulus to left ventricular activation time (s-LVAT) was 87.4±15.2 ms. In the control group, the paced QRS duration was 139.4±17.2 ms, and the s-LVAT was 79.9±14.1 ms. During the implantation, R-wave sensing and the pacing threshold of the HCM group were significantly higher than the control group (20.2±10.5 vs 12.5±5.9 mV, P < 0.05; 0.8±0.3 vs 0.6±0.2V/0.4 ms, P < 0.05). In addition, the fluoroscopic duration and procedural duration were longer in the HCM group (14.8±8.3 vs 10.3±6.6min, P = 0.07; 131.8±50.5 vs 101.4±41.6 min, P < 0.05). The lead insertion depth was 15±2 mm in the HCM group, and no procedure-related complications occurred. During the 12-month follow-up, pacing parameters remained stable and were of no significance in the two groups. The cardiac function did not deteriorate, and the left ventricular outflow tract gradient (LVOTG) did not increase in the follow-up. LBBP might be feasible and safe for NOHCM patients with conventional bradycardia pacing indication, and there is no deterioration in cardiac function and LVOTG of patients with NOHCM.

Novel non-invasive ECG imaging method based on the 12-lead ECG for reconstruction of ventricular activation: A proof-of-concept study.

Current non-invasive electrocardiographic imaging (ECGi) methods are often based on complex body surface potential mapping, limiting the clinical applicability. The aim of this pilot study was to evaluate the ability of a novel non-invasive ECGi method, based on the standard 12-lead ECG, to localize initial site of ventricular activation in right ventricular (RV) paced patients. Validation of the method was performed by comparing the ECGi reconstructed earliest site of activation against the true RV pacing site determined from cardiac computed tomography (CT). This was a retrospective study using data from 34 patients, previously implanted with a dual chamber pacemaker due to advanced atrioventricular block. True RV lead position was determined from analysis of a post-implant cardiac CT scan. The ECGi method was based on an inverse-ECG algorithm applying electrophysiological rules. The algorithm integrated information from an RV paced 12-lead ECG together with a CT-derived patient-specific heart-thorax geometric model to reconstruct a 3D electrical ventricular activation map. The mean geodesic localization error (LE) between the ECGi reconstructed initial site of activation and the RV lead insertion site determined from CT was 13.9 ± 5.6 mm. The mean RV endocardial surface area was 146.0 ± 30.0 cm2 and the mean circular LE area was 7.0 ± 5.2 cm2 resulting in a relative LE of 5.0 ± 4.0%. We demonstrated a novel non-invasive ECGi method, based on the 12-lead ECG, that accurately localized the RV pacing site in relation to the ventricular anatomy.

986 LEFT VENTRICULAR LEAD PLACEMENT FOR BIVENTRICULAR PACING INTO A LEFT LATERAL VEIN IN PATIENT WITH CONGENITAL ATRESIA OF THE CORONARY SINUS OSTIUM WHO UNDERWENT AORTIC VALVE REPLACEMENT

Abstract Introduction Coronary sinus ostial atresia (CSOA) is a rare congenital heart anomaly consisting in the occlusion of the coronary sinus (CS) outlet in the right atrium. It is one of the causes of placement left lead failure in CS during cardiac resynchronization therapy (CRT) device implantation. The persistence of the left superior vena cava is the most common pathway that allows venous blood flow to drain into the right atrium and can represent a new possible way to reach a left ventricular vein from the CS. Methods A 66-year-old male suffering from sarcoidosis was studied after an episode of syncope under exertion. EKG showed a 1st degree atrioventricular block and a left bundle branch block (LBBB) with wide QRS (170 ms). Echocardiography found left ventricle dilatation, severe systolic dysfunction, and a severe low-flow low-gradient aortic stenosis for which he underwent aortic valve replacement. After surgery and finding of 2nd degree type II atrioventricular block, CRT implant was performed but the procedure was complicated by the finding of CSOA. The insertion of the left quadripolar lead along a left branch of the occluded CS was achieved with a push-and-pull technique of the lead over a guidewire, after the retrieval and the cannulation of the persistent left superior vena cava. Results A new approach was applied on a rare case of CSOA found during CRT procedure. The contrast medium (CM) in the left subclavian vein revealed the existence of the left superior vena cava that was than cannulated. CM injection in CS highlighted a posterior left branch that was approached with a specific guidewire and a subselector after selective venography. With a fine technique of sliding of the lead on a tensioned guidewire, the quadripolar catheter was successfully placed in the left ventricular vein. Left-ventricle-right ventricle delays and catheter thresholds were tested and a final QSR duration of 90 msec in CRT mode was obtained. Conclusions This case-report shows a complex technique, reported in parallel with other similar procedures, to help the approach toward a rare anatomical variant of CSOA accompanied by persistent left superior vena cava when a CRT implant is needed after cardiac valve surgery in a patient suffering from sarcoidosis.