Europace Advance Access originally published online on January 9, 2006
Europace 2006 8(2):144-146; doi:10.1093/europace/euj025
© The European Society of Cardiology 2006. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
CRT
Cardiac resynchronization via the femoral vein: a novel method in cases with contraindications to the pectoral approach
Zaheer Yousef1,
Vincent Paul2 and
Francisco Leyva1,*
Department of Cardiology Good Hope Hospital, Sutton Coldfield UK ;
Department of Cardiology St Peters Hospital, Chertsey UK
Manuscript submitted 11 November 2004. Accepted after revision 30 September 2005.
Corresponding author. E-mail address: francisco.leyva{at}goodhope.nhs.uk
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Abstract
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We describe a case involving biventricular pacemaker implantation
via the right femoral vein in a patient where subclavian vein
access was not possible.
Key Words: Cardiac resynchronization, Biventricular pacemaker, Femoral vein
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Introduction
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Cardiac resynchronization therapy has been shown to benefit
patients with symptomatic heart failure.
1
In many cases, the
implant procedure can be technically challenging.
2 We recently
encountered a situation where bilateral subclavian vein access
was not possible and describe our successful implantation of
a biventricular pacemaker via the femoral approach.
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History
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A 64-year-old lady with severe heart failure due to anterolateral
myocardial infarction, with resting sinus rhythm and left bundle
branch block (PR interval: 160 ms and QRS duration: 175 ms),
presented with New York Heart Association (NYHA) class III heart
failure despite optimal medical therapy. Transthoracic echocardiography
revealed a dilated left ventricle (end-diastolic diameter: 8.15 cm),
anterior wall akinesia, severe systolic dysfunction (ejection
fraction: 15%), and moderate functional mitral incompetence.
Cardiac resynchronization therapy was recommended.
The left and right subclavian veins were inaccessible due to the relationship of the clavicle and first rib. The patient was, therefore, re-admitted for pacemaker implantation via the right femoral vein.
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Procedure
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A transverse incision was made 2 cm above the right inguinal
ligament, and access to the femoral vein was obtained. A long
splittable valved Safesheath guiding catheter (Pressure Products,
San Pedro, CA, USA) was advanced into the right atrium. Initial
attempts at gaining access to the coronary sinus with 6 French
gauge (F) Amplatz catheters (Cordis, Inc., Miami, FL, USA) were
unsuccessful; however, we were able to engage the coronary sinus
ostium with a 6F multipurpose catheter (Cordis, Inc.) (
Figs 1 and
2). Coronary sinography (
Fig. 3) identified an ideal
posterolateral tributary of the great cardiac vein (3 o'clock
position in the left anterior oblique view) into which an extra
length (88 cm), 6F, bipolar, over-the-wire left ventricular
lead (4194, Medtronic, Inc., Minneapolis, MN, USA) was negotiated.
Catheter support during left ventricular lead placement was
excellent (
Fig. 2), and angulation of the chosen lead enabled
stable positioning (
Fig. 4). For the right-sided leads,
bipolar, extra long (85 cm), 6.2F active fixation leads
(5076, Medtronic, Inc.) were positioned on the high interventricular
septum and in the right atrial appendage (
Fig. 5). Although
not standard issue, the extra length leads used in this case
are readily available from the manufacturer on request. After
fixing to the deep inguinal fascia, the leads were reflected
and tunnelled up into a low-mid abdominal pocket where an Insync
III (Medtronic, Inc.) generator was implanted. The patient's
body habitus precluded a lower implant site as originally described.
3
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Figure 1 Anteroposterior view. Contrast showing Safesheath positioned in right atrium (1) and multipurpose catheter (2) engaging coronary sinus ostium (3). Note the acute angulation of the coronary sinus.
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Figure 2 Anteroposterior view. Multipurpose catheter (1) and Safesheath (2) advanced over guide wire (3) to cannulate the coronary sinus. Note how, via the femoral approach, the guiding catheter straightens the approach to the coronary sinus, thus providing excellent support.
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Figure 4 Anteroposterior view. Inherent angulation of the bipolar 4194 lead provided stable placement of the left ventricular lead into the selected posterolateral branch of the great cardiac vein.
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Figure 5 Final lead placements in (A) left anterior oblique and (B) anteroposterior views. Left ventricle (1), right ventricle (2), and right atrium (3) leads.
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Discussion
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Conventional pacing via the femoral route is well-established;
3 however, our report of a biventricular pacemaker implant through
the femoral vein is novel and the first of its kind.
Our experience has shown that cannulation of the coronary sinus from an inferior approach may offer particular advantages. For example, the intubating catheter was able to straighten out curves leading to the coronary sinus and consequently provided excellent catheter support by forging a linear path to the coronary sinus (Fig. 3). Thus, we recommend that the femoral route for biventricular pacing be considered where the subclavian veins are inaccessible or where the morphology of the coronary sinus precludes superior catheter approach.
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Acknowledgements
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The technical advice given by Professor R. Sutton in the management
of this patient is greatly appreciated. The assistance of Mr
Andrew Ring (Medtronic, Inc.) is also appreciated.
Conflict of interest: ZY, VP and FL have received lecture fees and sponsorship from Medtronic, Inc., St Jude Medical and Guidant Corporation.
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References
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[1] Abraham WT and Hayes DL. Cardiac resynchronization therapy for heart failure. Circulation 2003; 108: 2596–603.
[Free Full Text][2] Bhatta L, Luck JC, Wolbrette DL, Naccarelli GV. Complications of biventricular pacing. Curr Opin Cardiol 2004; 19: 31–5.[CrossRef][Web of Science][Medline]
[3] Mathur G, Stables RH, Heaven D, Ingram A, Sutton R. Permanent pacemaker implantation via the femoral vein: an alternative in cases with contraindications to the pectoral approach. Europace 2001; 3: 56–9.[Abstract/Free Full Text]
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Abstract
Introduction