Europace Advance Access originally published online on July 1, 2008
Europace 2008 10(10):1234-1235; doi:10.1093/europace/eun179
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CASE REPORTS
Reversing cardiac resynchronization therapy non-responder status in a patient with a surgically placed epicardial left ventricular lead by switching to an active fixation coronary sinus lead
1 Medical Department, St Adolfstift, Hamburger Street 41, D-21465 Reinbek, Germany; 2 Cardiology Department, Albertinen-Krankenhaus, Süntelstrasse 11A, D-22457 Hamburg, Germany
Manuscript submitted 20 May 2008. Accepted after revision 12 June 2008.
* Corresponding author. Tel: +49 40 7280 5158; fax: +49 40 7280 2729. E-mail address: herbert.naegele{at}krankenhaus-reinbek.de
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Abstract |
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This report describes the reversal of a cardiac resynchronization therapy non-responder status in a patient with a surgically placed left ventricular lead by the use of a newly available active fixation coronary sinus lead.
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We report on a 55-year-old man with dilated cardiomyopathy. His left ventricular ejection fraction (LVEF) was 18% at the first presentation. He was in New York Heart Association (NYHA) stage III, despite of optimized medical therapy. Heart transplantation was considered as an option, but the patient also showed a complete left bundle brunch block. Therefore, he received a cardiac resynchronization therapy (CRT) defibrillator system in June 2006. Two dislocations of the coronary sinus (CS) lead occurred and, finally, a surgical approach was chosen. An epicardial (EPI) left ventricular (LV) lead was placed via left lateral thoracotomy. As the patient's condition did not improve (NYHA class III, brain natriuretic peptide (BNP) levels 3800 pg/mL, and LVEF 15%) during the next months, he was admitted for further evaluation. The pacemaker check revealed normal sensing and pacing thresholds, and his electrocardiogram appeared to show biventricular pacing with a reduction in the QRS width by 30 ms. Tissue Doppler imaging revealed the presence of asynchrony, despite formal correct biventricular pacing.
A review of the lateral X-ray revealed that the EPI lead was placed antero-laterally close to the right ventricular lead (Figure 1). The distance between the RV and the EPI leads equalled only about 25% of the total cardiac antero-posterior diameter. Therefore, a fourth revision was performed in February 2007, and a newly available active CS lead (model 4195, ‘Starfix’, Medtronic Inc., Minneapolis, MN, USA)1
could be successfully placed in a stable postero-lateral position, which is now very distant to the RV (Figure 1). Details of the implant procedure have been described elsewhere.1 The distance between the RV and the active fixation LV lead now equals more than 90% of the total cardiac antero-posterior diameter (Figure 1). The patient immediately felt better and has since an uneventful course in NYHA class I for more than 1 year. His ejection fraction increased to 35% and BNP levels decreased to 278 pg/mL. No more asynchrony could be noted by the tissue Doppler analysis. The patient's activity log most impressively showed a fast increase after the lead revision (Figure 1).
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) and between the right ventricular and the transvenous coronary sinus (4195) leads (
, date of the implantation of the active coronary sinus lead; 4195, Medtronic type 4195 active fixation coronary sinus lead.To the best of our knowledge, this is the first report of a patient in whom CRT non-responder (NR) status could be reversed by repositioning the LV leads. In this regard, the importance of the transverse interlead distance was highlighted.2
Antero-posterior chest X-rays should be critically reviewed in every CRT NR patient, even in the presence of EPI leads in context of existing CS angiograms in order to determine whether lead revision could reverse the patient's NR status. In this regard, several newly available leads and tools may be very helpful in difficult cases with lead problems or dislocations in prior interventions. Conflict of interest: none declared.
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TopAbstractCase reportReferences |
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[1] Nägele H, Azizi M, Hashagen S, Castel MA, Behrens S. First experience with a new active fixation coronary sinus lead. Europace (2007) 9:437–41. (Epub ahead of print, 21 April 2007).
[2] Heist EK, Fan D, Mela T, Arzola-Castaner D, Reddy VY, Mansour M, et al. Radiographic left ventricular–right ventricular interlead distance predicts the acute hemodynamic response to cardiac resynchronization therapy. Am J Cardiol (2005) 96:685–90.[CrossRef][Web of Science][Medline]
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