Left ventricular endocardial lead placement using a modified transseptal approach

Coronary sinus cannulation and placement of left ventricular (LV) leads can be difficult. Occasionally alternative approaches are required. We report the first case of a modified transseptal LV endocardial lead placement via the left axillary vein for cardiac resynchronization.     

Limiting left-sided catheter dwelling time using 3-D NavX to mark and reaccess the left atrium via prior transseptal puncture site

Introduction

Ablations requiring transseptal access to the left heart place patients at increased risk for stroke, bleeding, and post-procedural cognitive dysfunction and other complications. Diminishing left atrial catheter dwelling time may decrease these risks. 3-D NavX can be used to facilitate reaccess of transseptal puncture sites to allow catheter removal from the left atrium immediately after ablation, with reaccess through the prior transseptal site if required. Here, we describe the techniques employed and our experience using 3-D NavX to limit left atrial catheter dwelling time by marking and reaccess of the left atrium via the previously marked transseptal puncture site, a potentially radiation-free technique.

Methods

With the use of 3-D NavX, a right atrial geometry is created. The patent foramen ovale is marked by using a standard EP catheter, or the transseptal puncture site is marked using 3-D NavX by creating a unipolar electrode on the transseptal needle at the time of puncture and at the time of catheter withdrawal of the ablation catheter from the left atrium. Marking the access site allows the catheter to be removed from the left side of the heart immediately after the ablation. If reaccess to the left atrium is required, the previously marked transseptal site is used to navigate the ablation catheter to reaccess the left atrium. All patients <30 years who had undergone this technique were evaluated. Data gathered included patient demographics, need for and success of transseptal reaccess, left atrial catheter dwelling time, and complications.

Results

The transseptal site was marked by 3-D NavX in 54 patients. We were able to successfully reaccess the transseptal puncture site using 3-D guidance in all 10 patients where it was desired. In these 54 patients, the complication rate was low with one small post-procedural pulmonary embolism and one right bundle branch block. No other complications were noted. The median procedure time was 105 min (range 58–446 min), the median total fluoroscopic time for the entire procedure was 1.3 min (range 0.0–30.8 min), and the median left-sided catheter dwelling time was 21 min (range 6–112 min).

Conclusions

In our retrospective review, reaccess of transseptal puncture site was reproducible, and early removal of the catheter from the left side was without the need for repeat transseptal punctures. This technique decreases the time the catheter dwells in the left atrium, which could decrease risks such as clotting, bleeding, and cognitive dysfunction.     

Persistent left superior vena cava. Use of an innominate vein between left and right superior caval veins for the placement of a right ventricular lead during ICD/CRT implantation

This patient with congestive heart failure, atrial fibrillation,mild renal impairment, chronic lung disease, and diabetes mellitusunderwent CABG 2 weeks prior to the implantation of a combinedimplantable cardioverter     

A modified technique for carotid cannulation via the transfemoral approach, during angioplasty and stent placement

We report a modified technique for advancing a catheter or sheath into the right common carotid artery when the aortic arch anatomy is unfavorable.A standard 0.035-inch guidewire is passed into the right subclavian artery, and a diagnostic catheter is threaded over it, deep into the right axillary and brachial artery. This wire is exchanged for a stiffer wire (for example, a super-stiff Amplatz), and the catheter is removed. This stiff wire acts as an anchor and provides enough support for a sheath or a guide catheter to be easily advanced into the right brachiocephalic artery, up to its bifurcation into the subclavian and common carotid arteries. Another wire is then buddy-wired through the guide or sheath into the common carotid artery and is placed in a branch of the external carotid artery. The stiff wire is now slowly withdrawn from the subclavian artery, and as soon as its tip exits the subclavian ostium, the guide or sheath is advanced into the common carotid artery.This simple modification can improve the success rate of carotid cannulation via the femoral approach without increasing procedural risks.     

Method for the rapid and atraumatic insertion of permanent endocardial pacemaker electrodes through the subclavian vein.

One hundred sixty-four permanent pacemaker implantations through the subclavian vein were accomplished by 17 different physicians at four institutions utilizing a specially constructed peel-away introducer. Fourteen attempts (8.3 percent) to cannulate the subclavian vein were unsuccessful. There were four cases of pneumothorax (2.4 percent) and two cases of hematoma formation (1.2 percent). The procedure has the advantage of a rapid and atraumatic insertion of a variety of transvenous pacemaker electrodes, and the avoidance of surgical dissection for a venous entrance site.     

Transvenous ICD implantation after artificial tricuspid valve replacement. A new approach placing a transvenous ICD lead in the mid cardiac vein of the coronary sinus

Summary Implantation of a transvenous device in patients with a tricuspid valve replacement or a complex congenital heart disease with no access to the right ventricle represents problems. The lack of access to the right ventricle might preclude transvenous placement of a defibrillation lead at ICD implantation. A young patient (21 years) with a history of severe chest trauma with rupture of the tricuspid valve as well as the right coronary artery and consecutive inferior myocardial infarction was initially treated with tricuspid valve replacement (St Jude Medical artificial prosthesis, 33 mm) and a bypass graft to the right coronary artery. Four years later, the patient was admitted with a hemodynamically not tolerated ventricular tachycardia (VT: CL 250 ms, LBBB, left axis). The VT could be reproduced during electrophysiological testing. An ICD was implanted subpectorally in combination with a transvenous active fixation ICD lead. The transvenous ICD lead was placed via a guiding catheter into a coronary sinus branch (middle cardiac vein). Acceptable pacing and sensing values could be obtained. The defibrillation threshold was 25 J. In conclusion transvenous ICD lead implantation into a side branch of the coronary sinus in combination with a pectorally implanted “active can” ICD device seems to be an alternative approach. This approach may avoid implantation of additional subcutaneous defibrillation leads or even thoracotomy for ICD implantation.     

Failure of endocardial biopsy from the internal jugular vein due to endocardial scar: a new indication for the femoral venous approach.

Following cardiac transplantation, patients undergo serial endomyocardial biopsies to evaluate rejection, usually by the internal jugular approach. A case report and data are presented that demonstrate that this approach becomes less efficient and occasionally impossible in the third year after transplant (53% success rate per biopsy attempt) as compared to the first year after transplant (80%) probably due to the development of endocardial scar in the area sampled by the bioptome. Alternatively, one can change to the femoral venous approach which continues to have a high success rate in the third year after transplant (83%) because a different area of the interventricular septum is sampled when this approach is used.     

Testing a new mechanism for left interventricular septal pacing: the transseptal route; a feasibility and safety study.

AIMS: To prove the feasibility and safety of left interventricular septal pacing. BACKGROUND: Right ventricular apical pacing is an established but haemodynamically less favourable pacing method compared with transvenous left ventricular pacing. Alternatively, we propose a simple septal screw-in lead for left interventricular septal pacing. METHODS: A pacemaker lead with a long insulated screw with the two distal windings forming an active tip was implanted from the right side of the interventricular septum to the subendocardial left side in six goats. A special guiding sheath enabled stable, easy, and swift implantation of the lead. The implantation was performed using fluoroscopy together with. normal and contrast echocardiography (via the long pre-shaped sheath) and electrocardiographic signals (His-bundle recordings in conjunction with atrial and ventricular intracardiac signals). The screw was also positioned at other locations along the free wall, and at the interventricular septum to assess possible adverse effects at other sites. RESULTS: An average of 2.2 +/- 1.5 positions per goat was attempted. No adverse effects were noticed during implantation or at necropsy. In two goats, the final position was at the junction of the right ventricular wall and the interventricular septum. Parameters at the final positions were as follows: the pacing threshold was 1.3 +/- 1.0 V at 0.5 ms; the pacing impedance was 1022 +/- 463 omega at 4.8 V and 0.5 ms. R-wave amplitudes were 17.6 +/- 7.6 mV. CONCLUSION: Left interventricular septal pacing is feasible. In our study it was safely performed in six goats. The pacing threshold was low, and the stability of the lead system was good. Implantations in humans and animals and haemodynamic evaluations are needed to reveal the potential benefits of this new form of left interventricular septal pacing.     

Hypoplastic left heart syndrome with right aortic arch, bilateral arterial ducts and origin of the left subclavian artery from the left pulmonary artery.

The rare association, in a left-sided heart with hypoplastic left heart syndrome, of right aortic arch, bilateral patent arterial ducts and origin of the left subclavian artery from the left pulmonary artery are described. Cardiac catheterization was performed because of the abnormal anatomy of the arch noted at echocardiographic examination. This abnormality is of surgical importance when planning the Norwood operation.     

Intracoronary stent implantation: new approach using a monorail system and new large-lumen 7F catheters from the brachial route.

In this brief report we describe a case of successful multivessel PTCA with intracoronary stent implantation using a new large-lumen 7F catheter from the left brachial approach. The application of this technique should be considered for intravascular stent implantation when anticoagulation ideally should not be interrupted or in anatomical situations limiting femoral vascular access.     

MR angiography of the anomalous branching of aortic arch and left subclavian artery arising from Kommerell's diverticulum. Case report.

We report the magnetic resonance (MR) angiographic findings of an asymptomatic case with abnormal branching of aortic arch and Kommerell's diverticulum, which to our knowledge has not been described previously.     

Percutaneous coronary intervention of a circumflex artery chronic total occlusion using the retrograde approach via ipsilateral collateral circulation from the left anterior descending artery

Retrograde recanalization techniques have markedly improved success rates of attempts to open chronic coronary occlusions in symptomatic patients. A contralateral artery with a collateral channel to the distal segment of the occluded artery is traversed and the vessel is then wired and dilated retrogradely. Occasionally only an ipsilateral collateral is available. We describe the first case of retrograde recanalization of a dominant circumflex artery via a septal collateral channel and discuss the issues surrounding the use of the ipsilateral collateral approach to recanalization of a chronically occluded artery.     

Resection of metastatic pulmonary lesion of ossifying fibromyxoid tumor extending into the left atrium and ventricle via pulmonary vein.

The ossifying fibromyxoid tumor (OFMT) of soft parts is a rare soft tissue neoplasm of uncertain lineage. The most common metastases are found in the lung. Herein, we present the first case report of pulmonary metastasis of ossifying fibromyxoid tumor with intracardiac extension, which was resected carefully using cardiopulmonary bypass and cardiac arrest. Subsequently pulmonary left lower lobectomy was performed. The patient recovered uneventfully and was discharged in after a few days. Recently, OFMT has been considered as a tumor of intermediate malignancy. We recommend wide surgical excision of primary tumor and radiotherapy. Early follow-up is mandatory.     

Intracoronary stent implantation: New approach using a monorail system and new large-lumen 7 f catheters from the brachial route

In this brief report we describe a case of successful multivessel PTCA with intracoronary stent implantation using a new large-lumen 7F catheter from the left brachial approach. The application of this technique should be considered for intravascular stent implantation when anticoagulation ideally should not be interrupted or in anatomical situations limiting femoral vascular access.