Coronary sinus lead extraction in the era of cardiac resynchronization therapy: single center experience

As the number of coronary sinus (CS) lead implantations for cardiac resynchronization therapy increases so will the need for extraction of these leads. The safety of extraction of leads from the branches of the CS has not been reported. We reviewed our database of patients undergoing pacemaker lead extraction from January 2002 through February 2004 at our institution. Of 149 patients referred for lead extraction, 14 (9%) had a biventricular device. The indications for lead extraction were infection, lead malfunction, and exit block. The duration of CS lead implants ranged between 2 and 43 months (mean 17 months). All 14 CS leads were removed successfully using nonsurgical lead extraction techniques. Three leads that were in place the longest (≥27 months) were removed via the femoral vein approach due to fibrous attachment of the CS lead body to the other pacemaker leads. The leads were structurally intact and without any significant fibrosis of their tips upon visual inspection. There were no major complications of CS laceration, hypotension, pericardial effusion, or excessive blood loss associated with any of the extraction procedures. CS leads were removed safely, successfully and with relative ease based on our experience in this small cohort of patients.     

Transvenous implantation of a coronary sinus lead for left ventricular pacing after cutting balloon angioplasty

We describe a patient in whom a localized proximal vein stenosis at the only possible target vein precluded placement of a coronary sinus lead for left ventricular (LV) pacing. After multiple attempts to perform venoplasty with both compliant and noncompliant balloons, a cutting balloon relieved the obstruction, and an LV pacing lead was successfully placed in the midportion of this lateral vein.     

Large, single-center experience in transvenous coronary sinus lead extraction: procedural outcomes and predictors for mechanical dilatation

Background: The aim of this study was to evaluate procedural outcomes of coronary sinus (CS) lead extraction, focusing on predictors and need for mechanical dilatation (MD) in the event that manual traction (MT) is ineffective. Methods: The study assessed results in 145 consecutive patients (age 69 ± 10 years; 121 men)—a total of 147 CS pacing leads—who underwent transvenous CS lead removal between January 2000 and March 2010. Results: All leads but one (99%) (implantation time 29 ± 25 months) were successfully removed. MT was effective in 103 (70%), and MD was necessary in the remaining 44 (30%) procedures. In multivariate analyses, unipolar design (odds ratio [OR] 3.22, 95% confidence interval [CI] 1.43–7.7; P = 0.005) and noninfective indication (OR 4.8, 95% CI 1.8–13, P = 0.002) were independent predictors for MD (P < 0.0001), with a predictive trend for prior cardiac surgery (OR 2.2, 95% CI 0.98–5.26; P = 0.06). Five (3.4%) complex procedures required a transfemoral vein approach (TFA) or repeat procedure. No deaths occurred, and there was one major complication (0.7%), cardiac tamponade, after MT. No complication predictors were identified. Conclusions: CS leads were safely and effectively removed in nearly all patients, and 70% were removed with MT alone; 30% required MD. Preoperative predictors suggesting the need for MD or TFA were noninfective indication and unipolar lead design. Complications were rare, and there was no predictable pattern among MT or MD removal techniques. (PACE 2012; 35:215–222)     

Coronary vein angioplasty with noncompliant balloon for resistant coronary vein stenosis during left ventricular lead implantation

This report describes a patient who underwent cardiac resynchronization therapy (CRT) in the setting of a severe stenosis in the lateral coronary vein that prevented passage of a left ventricular lead. The stenosis was unresponsive to standard compliant balloon dilatation but was successfully treated with a noncompliant balloon. Venoplasty with noncompliant balloon should be considered for resistant coronary vein stenosis encountered during CRT device implantation.     

Left ventricular pacing lead positioning in the target vein of the coronary sinus: description of a challenging case

The optimal left ventricular pacing location for cardiac resynchronization therapy should be individualized according to the site of maximal mechanical delay. However, the presence of vein stenosis or kinking in coronary sinus (CS) anatomy could hamper lead implantation in the target vessel. We describe the case of a patient with dilated cardiomyopathy and a dual-chamber pacemaker referred for upgrading to a biventricular device owing to New York Heart Association III heart failure symptoms. Tissue Doppler analysis before implantation showed that the area of maximum activation delay was located in the posterolateral region of the left ventricle. Insertion of the lead into a posterolateral vein of the CS by means of the standard over-the-wire approach was unsuccessful due to the presence of a stenosis at the ostium of the vein. Lead placement in an anterior vein of the CS was unsatisfactory owing to a poor local delay from QRS onset. After balloon vein angioplasty, the pacing lead passed through the stenotic tract at the ostium of the target vein and was successfully positioned in the posterolateral region. Three months after pacemaker implantation, echocardiography showed an important reduction in the indexes of both inter- and intraventricular asynchrony and a significant left ventricular reverse remodeling     

Successful implantation of a coronary sinus lead after stenting of a coronary vein stenosis

Dislodgment of the coronary sinus lead was observed in a 79-year-old patient 8 months after implantation of a biventricular pacing system. A severe stenosis in the posterolateral branch, in which the lead was previously positioned, prohibited reinsertion of the lead. Because no other branches with adequate anatomy for lead insertion were available in the targeted area, the stenosis was dilated and stented. Subsequently, the left ventricular lead could be reimplanted in the same vessel.     

Advanced image fusion to overlay coronary sinus anatomy with real-time fluoroscopy to facilitate left ventricular lead implantation in CRT

Background: Failure rate for left ventricular (LV) lead implantation in cardiac resynchronization therapy (CRT) is up to 12%. The use of segmentation tools, advanced image registration software, and high‐fidelity images from computerized tomography (CT) and cardiac magnetic resonance (CMR) of the coronary sinus (CS) can guide LV lead implantation. We evaluated the feasibility of advanced image registration onto live fluoroscopic images to allow successful LV lead placement. Methods: Twelve patients (11 male, 59 ± 16.8 years) undergoing CRT had three‐dimensional (3D) whole‐heart imaging (six CT, six CMR). Eight patients had at least one previously failed LV lead implant. Using segmentation software, anatomical models of the cardiac chambers, CS, and its branches were overlaid onto the live fluoroscopy using a prototype version of the Philips EP Navigator software to guide lead implantation. Results: We achieved high‐fidelity segmentations of cardiac chambers, coronary vein anatomy, and accurate registration between the 3D anatomical models and the live fluoroscopy in all 12 patients confirmed by balloon occlusion angiography. The CS was cannulated successfully in every patient and in 11, an LV lead was implanted successfully. (One patient had no acceptable lead values due to extensive myocardial scar.) Conclusion: Using overlaid 3D segmentations of the CS and cardiac chambers, it is feasible to guide CRT implantation in real time by fusing advanced imaging and fluoroscopy. This enabled successful CRT in a group of patients with previously failed implants. This technology has the potential to facilitate CRT and improve implant success. (PACE 2011; 34:226–234)     

Double wire technique to catheterize sharply angulated coronary sinus branches in cardiac resynchronization therapy

Placing a pacing lead for left ventricular pacing through the coronary sinus can be hampered by anatomic obstacles. In this case report we describe a technique that can overcome the problem of sharply angulated coronary sinus branches by using simultaneously two guidewires in the target vessel.     

Fluoroscopic left ventricular lead position and the long-term clinical outcome of cardiac resynchronization therapy

Background: To determine the effects of left ventricular (LV) lead tip position on the long‐term outcome of cardiac resynchronization therapy (CRT). Setting: Cardiac device therapy center. Patients: Five hundred and fifty‐six patients (age 70.4 ± 10.7 years [mean ± standard deviation]). Interventions: CRT‐pacing or CRT‐defibrillation device implantation. Main outcome measures: Cardiovascular mortality and events over a maximum follow‐up period of 9.1 years. Results: Hazard ratios (HRs [95% 785]797) for cardiovascular mortality, adjusted for age, gender, QRS duration, heart failure etiology, New York Heart Association class, and presence of diabetes and atrial fibrillation, were derived for LV lead tip positions in terms of veins, circumferential, and longitudinal positions with respect to the LV chamber. For vein position, these were 1.07 (0.74–1.56) for anterolateral vein position and 1.24 (0.79–1.95) for the middle cardiac vein, compared with a posterolateral vein. For circumferential lead tip position, HRs were 1.56 (0.73–3.34) for anterolateral and 1.57 (0.76–3.25) for lateral, compared with posterior positions. For longitudinal lead tip positions, HRs were 1.02 (0.72–1.46) for basal and 1.21 (0.68–2.17) for apical, compared with mid‐ventricular positions. The risk of meeting the composite endpoints of cardiovascular death or hospitalizations for heart failure and death from any cause or hospitalizations for major adverse cardiovascular events was similar among the various LV lead tip positions. Conclusions: The position of the LV lead over the LV free wall, assessed by fluoroscopy, has no influence over the long‐term outcome of CRT. (PACE 2011; 34:1–13)     

Postmortem anatomy of the coronary sinus pacing lead

Biventricular pacing nowadays represents a recognized method of nonpharmacological treatment of severe congestive heart failure refractory to medication. A growing number of biventricular implants is likely to bring an increasing demand for the extraction of specially designed coronary sinus (CS) leads for left ventricular pacing. There is a lot of data regarding conventional pacing or defibrillation lead extractions, but only very limited experience with the CS lead extractions. We describe the pathological-anatomical findings of a woman who died after 26 months postimplantation due to refractory ventricular fibrillation with focus on the left ventricular pacing lead course and feasibility of extraction.     

心脏再同步化治疗引起冠状窦夹层2例

病例1:男,60岁,因"劳力性呼吸困难6年,加重4个月"入院.既往无高血压和冠心病史.查体:血压130/70 mmHg,双肺底少许湿啰音,心界向左下扩大,心率92次/分,律不齐,心音低钝,双下肢轻度水肿.ECG:心房纤颤,完全性左束支传导阻滞.     

Left ventricular lead stabilization utilizing a coronary stent

Cardiac resynchronization therapy has been recently demonstrated to have a mortality and morbidity benefit in heart failure (HF) patients with cardiac dyssynchrony. Currently, the most widely used method of left ventricular (LV) lead placement involves transvenous placement of leads via the coronary sinus (CS) and into a tributary branch. Lead dislodgement is a common cause for reoperation, and continues to be a common problem despite advances in equipment and operator techniques. We describe a case where a coronary stent was placed in a lateral branch of the CS to stabilize the lead against the vessel wall.     

Pacing lead adhesions after long-term ventricular pacing via the coronary sinus

Left ventricular pacing via the coronary sinus is being increasingly used. There is little data to guide possible lead extractions that might be required in the future. Significant adhesions to the coronary veins were found 12 years after placing a pacing lead in the posterolateral coronary vein in a man with double inlet left ventricle and severe subpulmonary stenosis who had undergone a Fontan operation. The appearances suggest that percutaneous extraction from the proximal coronary sinus may be feasible but that difficulty may be encountered if the lead tip is placed into the distal coronary veins.     

Removal of coronary sinus intima by a guidewire during cardiac resynchronization therapy

Previously, complications associated with the placement of the left ventricular pacing lead were reported in 1.9-6% of cases. We describe a case with a stripping of venous intima from the coronary sinus by a guidewire during a left ventricular lead implantation. Judging from this case, the firm guidewire and coronary catheter should not be used within the coronary sinus.     

Novel lead anchor technique using an active fixation quadripolar left ventricular lead in cardiac resynchronization therapy

In this report, we present a case of successful advancement of a LV lead into tortuous vessels. This was achieved by deep engagement of the coronary sinus with a cannulation catheter by applying the anchor technique using the Medtronic Attain Stability Quad lead.     

Utilization of intracardiac echocardiography to access the coronary sinus for left ventricular lead placement

This is a presentation of a case series of 10 consecutive patients undergoing implantation of cardiac resynchronization therapy defibrillator (CRT-D). Intracardiac echocardiography (ICE) is utilized to gain access to the coronary sinus. The method used is detailed with a brief discussion of observations gained from this early experience.