HK-IN-PACEHeart Rhythm Refresher Course 2013Module 1 Cardiac Pacing: Concepts and Practice

Implantation Techniques: From venous access to Lead implantationDr. K ChanRuttonjee and Tang Shiu Kin Hospitals

Transvenous CRT implant

Venous access

Cannulation of coronary sinus

Coronary sinus venogram

Left ventricular leads implantation

Removal of implant tools

Troubleshooting

Venous accessSubclavian vein puncturePuncture site: Junctional of medial and mid 3rd of clavical aiming towards sternal notch

Axillary vein puncturePuncture site: 1 or 2 cm medial and parallel to the deltopectoral groove @ 1 FB below coracoid process

Cephalic vein cutdownLandmark: Deltopectoral groove fat pad

Surface Anatomy Heart Rhythm 2006;3:366-9

Pocket Creation Pre-pectoral plane Heart 2009;95;259-264Pre-pectoral plane: 3 featuresShiny/white prepectoral fasciaPainfulFasciculation with electrocautery

Anatomy of Subclavian/ Axillary/ Cephalic Venous System Heart Rhythm 2006;3:366-9

Fluroscopic Anatomy of Subclavian/ Axillary/ Cephalic veins Heart 2009;95;259-264

Subclavian/Axillary Vein PunctureSuclavianAxillary Heart Rhythm 2006;3:366-9

Axillary Puncture Heart 2009;95;259-264

Cephalic Cutdown Heart 2009;95;259-264

Pros and Cons of Different Venous Access Routes Heart 2009;95;259-264

Retained Guidewire Technique

Insertion of guide-wire and sheath Heart 2009;95;259-264

Anatomy of Coronay SinusOs of Coronar Sinus

Coronary Venous AnatomyCM Yu. Cardiac Resynchronization Therapy. 2nd Ed. 2008

Cannulation of the Coronary Sinus

Techniques of CS CannulationDirect guiding catheter cannulation

Guidewire (0.035) guided cannulation

EP Catheter guided cannulation

Thebasian Vale & Eustachian Ridge Block CS assessEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

When the tip of catheter starts up too high above CSCouterclockwise torque directs the tip downward & to the left / away from CSEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

When the tip of catheter starts up too low below CSEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed. Couterclockwise torque also directs the tip downward & away from CS

CS Cannulation TechniqueThe Eustachian ridge and Thebesian valve form a pocket that catches the tip

Techniques:

Advance the guiding catheter across the tricuspid annulus into RV

2. Slightly withdraw

3. Apply counter-clockwise torque to direct the guiding catheter posteriorly into CS os

Choice of Appropriate Guiding Catheter according to anatomyIn dilated hearts, large proximal cure carries the tip of catheter across RA/Eustachian Ridge and lifts the tip above the os of CS

Proximal Curve lying against the lateral wall of RA/ Eustachian Ridge provides extra support and stability

Choice of Guiding CathetersGuidant Extended HookBoston Scientific& MedtronicMultipurposeMedtronic AttainExtended HookEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Biotronik Guiding CathetersDiagnostic Catheter TechniqueLeft internalmammary(LIMA)Multi Purpose(MP)Amplatz left

Boston Scientific Guiding Catheters

St Jude Cardiac Positioning System

Medtronic Attain Command CathetersStandard AnatomyMultipurpose (MP)

Dilated Heart/ superior CS takeoff: Extended Hook Extra LargeAmplatz

Deep seating required/ tapered shafts:Straight/ MP ExtraMB2 Extra

R sided implant:MP RightStraight

Medtronic Attain Select Subselection catheterCS with Sigmoidal takeoff

Telescoping a subselection catheter in a guiding catheter to create desirable shape

Subslection of CS branches90/ 130 degreesOuter diameter 7.1FrInner diameer 5.7Fr

Combination of Telescoping Guiding Catheters to tailor desirable shapes to faciliate CS cannulationEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Guidewire guided CS CannulationEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Sub-selection catheter guided CS cannulationEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Coronary Sinus Venogram

Purposes of CS VenogramPre-shot to grossly assess CS size before balloon inflation (avoid balloon dissection of CS)

Assess CS Venous Anatomy for selection of LV lead (Size & implantation site)

Acquire Orthogonal views to assist side branch cannulation

Assess anatomical variations (Valves/ Angulation/Persistent LSVC/Thrombosis )

RAO Venogram

LAO Venogram

Occlusive CS VenogramEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

CS Venogram - AP

CS Venogram - LAO

CS Venogram - RAOPosterior Cardiac Vein

Selecting vein for CRT lead placementA. Postero-lateral cardiac veinB. Lateral cardiac veinC. Posterior cardiac veinD. Middle cardiac veinF. Anterior cardiac vein

ABCDE

Which CS branch to use?

General rule of thumb: Good capture thresholdGood stabilityNon-apical (preferably basal/lateral)Greatest separation between RV and LV tipAvoid infarcted myocardium if possibleNo phrenic nerve stimulation (or pacing threshold

LV Lead positioned in the apical regionAssociated with unfavorable outcome

Choose non-apical position

LV Lead Implantation

Biotronik LV Leads Corox

A complete set of support tools and LV leads including ACUITYTM Spiral with a 1,35mm (4F) tapered LV lead tip profile and a unique 3D helical fixation for predictable and successful CRT implants

8 different types of RAPIDO CS-Guiding Catheters4 different types of EASYTRAK and ACUITY Left Ventricular LeadsEASYTRAK 2BipolarSteroid-elutingPassive fixationEASYTRAK 3BipolarSteroid-elutingHelix memory shape fixationACUITY SteerableBipolar3D Tip ControlACUITY SpiralUnipolar1,35 mm (4F) Tapered Lead Tip ProfileBoston Scientific LV Leads

Boston Scientific Acuity Spiral LV Lead

St Jude QuickFlex LeadsSt Jude

St Jude Quadripolar LV Lead

St Jude Quadripolar LV Lead

Summary of Left Ventricular LeadsEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

LV Lead implantation techniques

Guidewire assisted LV Lead ImplantEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Buddy wire techniqueEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Subselection Catheter assisted LV Lead ImplantAdvance and pull-backEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Subselection Catheter assistedLV Lead ImplantationEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Telescoping Hockey StickEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Telescoping subselection guding catheter assisted LV lead implantEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Balloon Venoplasty assistedLV Lead ImplantEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Anchoring balloon in an upstream venous branch

PACE 2009;32:1577-81

Things to check before closureLead impedance/Sensing/Pacing thresholds (check different pacing configurations/ watch out for anodal capture)

Recheck diaphragmatic pacing/phrenic nerve stimulation (10V)

Recheck electrical and radiological stability with breathing maneuvers

Ensure adequate/ but not excessive lead laxity

Removal of implant tools

Withdrawal of guiding catheter out of CS os with wire/stylet support before slitting Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed. Dropping of guiding catheter into RA can dislodge the LV Lead Need to withdraw guiding catheter out of CS os before slitting

Maintain curvature in the stylet upon guiding catheter withdrawalEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed. Straight stylet can dislodge LV lead

Maintain a proximal curve in the LV Lead catheterEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed. Maintain a proximal curve/ laxity in LV lead upon guiding catheter withdrawal to avoid dislodging the LV lead

Maintain laxity of LV leadEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Slitting the SheathsEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Slitting TechniqueCorrect Technique Maintaining hub in line with slitter Force of pulling should be Coaxial with the lead/guidingIncorrect Technique - Pulling catheter shaft at angle to slitterForehand holding the hub should remain steady

LV Lead Implant ComplicationsVascular complications/ bleedingPneumothoraxAir emoblism/ pulmonary embolismCoronary venous dissection/perforationCardiac tamponade Lead related complications Valvular injury InfectionCardiac/ neurological complications

Troubleshootings Difficult LV Lead ImplantationAbsence of subclavian/axillary venous access/ thrombosisSubclavian balloon venoplastyEpicardial/ Endocardial LV Lead implantationIliac implant ApproachEustachian ridge/ Thebasian valveUse guiding with different curvaturesValve of VieussensUse telescoping deflectable guiding/0.035guide wire to nudge openTortuous/sigmoidal CS takeoffUse telescoping subselection catheter to change curvature Use anchoring balloonCS venous stenosisBalloon venous angioplastyDifficulty advancing the leadBuddy wire/ Subselection catheterAnchoring balloonGoose-neck Snare/Tretrograde wiring technique (Seth Worley)

Iliac implant TechniqueEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Valve of VieussensGently attempt to pass wire; valve may open/close Or, insert 0.035 wire / deflectable catheter to gently nudge openDo proof shot Track the guide catheter over deflectable catheterRepeat proof shot thru guide

TroubleshootingsHigh LV lead capture thresholdsDiaphragmatic pacing/Phrenic nerve stimulation

Solutions: Repositioning of LV lead (advance or withdrawal)Try threshold test with different pulse width configTry bipolar vs unipolar thresholdsElectrical repositioning: changing pacing configurations (e.g. LV tip/ring to RV coil/ RV ring)

TroubleshootingEasy LV Lead dislodgement:

Active fixation lead inside CSStenting of LV lead inside CS (problem with future lead extraction)Impingement lead technique (putting an extra LV lead in CS for fixation)

TroubleshootingWhat if transvenous LV lead implantation fails:

Epicardial LV Lead implantation

Endocardial LV Lead implantation

Epicardial LV Lead ImplantEllenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Novel CRT Implant Techniques

CT Fluoroscopy Fusion

Medtronic ConfidentialNavigate real-time in fluoroSelect preferred target site and choose LV lead Obtain anatomical information about target & match best leadDetect exactly where lead is & how far from targetCardioGuide 3D System: Optimize LV Lead Implant*

Medtronic Confidential

Magnetic Navigation - Stereotaxis

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy 3rd Ed.

Thank you Compliments

Presentation materials kindly provided by MedtronicBiotronikSt. JudeBoston Scientific

August, 2001For Medtronic Use Only***June, 2001For Medtronic Use Only*Point out:Long axial view, making spine to the leftSternum is on the rightRibs point downward and to the right*Point out:Short axial view of the patientSpine is on the leftSternum is on the rightRibs point downward and to the leftAugust, 2001For Medtronic Use Only*The best performance for LV pacing is thought to occur when in a lateral or posterior lateral position.

Butter C, Auricchio A, Stellbrink C, Fleck E, Ding J, Yu Y, Huvelle E, Spinelli J. Effect of resynchronization therapy stimulation site on the systolic function of heart failure patients. Circulation 2001;104:3026-3029Acute study in 30 pts (mean NYHA class 2.7, mean QRS duration 152 ms, mean PR interval 194 ms, mean EF 23%) from PATH-CHF-II study. Measured changes in dP/dt max and aortic pulse pressure between pacing in the LV freewall and the LV anterior wall in both LV only and BiV modes with temporary leads in the RA and the RV apex. LV freewall pacing (in either LV only or BiV modes) showed significantly greater changes in dP/dt and aortic pulse pressure compared with anterior wall pacing.Ansalone G, Giannantoni P, Ricci R, Trambaiolo P, Fedele F, Santini M. Doppler Myocardial Imaging to Evaluate the Effectiveness of Pacing Sites in Patients Receiving Biventricular Pacing. J Am Coll Cardiol 2002;39:489-499 Study to compare efficacy of biventricular pacing (BIV) at most delayed wall of LV and at other LV walls. In 31 pts w/ advanced non-ischemic HF (LBBB, NYHA III-IV, LVEF