Europace Advance Access originally published online on January 10, 2006
Europace 2006 8(2):147-150; doi:10.1093/europace/euj023
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CRT
Permanent pacing using a coronary sinus lead in a patient with univentricular physiology: an extended application of biventricular pacing technology
Second Section of Cardiology Department of Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Tao-Yuan Taiwan ; Nizams Institute of Medical Sciences Hyderabad India
Manuscript submitted 1 March 2005. Accepted after revision 30 September 2005.
Corresponding author. Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei, Taiwan. Tel: +886 3 3281200; fax: +886 3 3289134. E-mail address: chcwang{at}adm.cgmh.org.tw
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Abstract |
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In the past, patients requiring permanent pacing with difficult right ventricular (RV) access were usually subjected to epicardial pacing by a surgical approach. This report describes a young patient with univentricular physiology following repeated palliative surgery for complex congenital heart disease. The patient had symptomatic complete heart block and a dual chamber pacemaker with transvenous atrial and ventricular leads was implanted successfully. The ventricle was paced through the posterolateral cardiac vein with a lead specially designed for cardiac resynchronization therapy. This case illustrates an extended application of the recently developed coronary sinus lead in selected patients, when conventional RV endocardial pacing is impossible.
Key Words: Pacing, Pacemaker, Congenital heart disease, Heart block
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Introduction |
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Implanting pacemakers in patients with difficult or no right ventricular (RV) access is a challenging task. A surgical approach with epicardial ventricular pacing was the usual option in the past. However, this required at least a limited thoracotomy and the long-term pacing threshold and stability of the lead were generally inferior to that achieved with transvenous endocardial pacing.1
With the development of the coronary sinus (CS) lead for cardiac resynchronization therapy (CRT), this lead may be an effective alternative to the conventional RV pacing lead for transvenous implantation in patients with difficult or no RV access. This report demonstrates an application of CS lead for permanent ventricular pacing in a patient with univentricular physiology and complete atrioventricular (AV) block. |
Case report |
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A 17-year-old female with complex congenital heart disease was admitted to Chang Gung Memorial Hospital for recurrent dizzy spells and general physical weakness. Electrocardiogram (ECG) upon admission revealed complete AV block and a narrow QRS escape rhythm (Fig. 1A). Her complex congenital heart disease comprised endocardial cushion defect, ventricular inversion, and pulmonary artery atresia. The patient had undergone right and left Blalock–Taussig (B–T) shunt procedures at 5 and 6 years of age, respectively. Bilateral B–T shunt ligation and a modified Fontan operation were performed when she was 8 years old with closure of the right-sided mitral valve and a large atrial septal defect. The superior vena cava was connected to both right and left pulmonary arteries (Fig. 2D). Surgical correction isolated the right atrium (RA) and established communication between the right and left ventricles through a large ventricular septal defect, which acted as univentricular physiology. Initial post-operative AV conduction was normal and worsened gradually to complete AV block identified during follow-up examination. Therefore, implanting a dual chamber pacemaker using a CS lead transvenously for ventricular pacing was scheduled considering her underlying cardiac anatomy. Catheterization was performed prior to pacemaker implantation to determine cardiac anatomy in detail (Fig. 2). The RA was accessed through the left cephalic vein. The CS ostium was localized with a 6-French steerable tip, quadripolar electrode catheter. A specially designed CS guiding catheter for CRT (MB-1 catheter, Medtronic, Minneapolis, MN, USA) was employed to cannulate the CS. An occluded CS venogram was obtained (Fig. 3A and B) with a balloon-tip catheter. Using the CS venogram as a road map, a 0.014 in. coronary intervention guide wire (Extra S'port, Guidant, St Paul, MN, USA) was advanced into the posterolateral cardiac vein (PLCV). A specially designed over-the-wire CS pacing lead (Attain OTW 4193, Medtronic, USA) was then advanced over the wire into the PLCV (Fig. 3C and D). The CS lead pacing threshold was 1.5 V at 0.5 ms and the measured R-wave amplitude was 16.0 mV. No phrenic nerve stimulation at maximal output was noted. A bipolar active fixation lead (CapSurefix 5076, Medtronic) was positioned at the free wall of the anterior RA. Both leads were connected to a dual chamber pacemaker (KAPPA KDR 403, Medtronic). Post-operative ECG showed a positive-paced QRS configuration in V1 lead (Fig. 1B). Post-operatively, the patient achieved total relief from her dizzy spells and her exercise tolerance improved from New York Heart Association functional Class II to I. During follow-up, both atrial and ventricular lead parameters were all within satisfactory ranges. The measured R-wave amplitude at 6-month follow-up was 15.7 mV and the ventricular pacing threshold was 1.5 V at 0.2 ms.
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Discussion |
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Complex congenital heart disease requiring pacing therapy, especially those without RV access, is a unique challenge to physicians. Warfield et al.2
reviewed 973 patients with univentricular physiology who underwent corrective surgery and reported that 32 (2.98%) of these patients required permanent pacing. Almost all patients requiring permanent ventricular pacing received epicardial pacing. Only one patient with double inlet left ventricle and pulmonary stenosis who did not undergo reconstructive surgery underwent transvenous atrial and ventricular pacing with a dual chamber pacemaker. However, a fatal thromboembolism from the atrial lead developed despite anticoagulation therapy 18 months after surgery. After the Fontan procedure, patients have increased risk of thromboembolism, a significant concern when performing endocardial pacing. Shah et al.3 analyzed mid-term follow-up data from patients who underwent endocardial atrial pacing following the Fontan procedure. They concluded that angiography should be performed pre-operatively to identify a R–L shunt, and closing the shunt prior to endocardial lead implantation is preferable, when possible. Prophylactic anticoagulation therapy should be administered in the presence or absence of a R–L shunt. With these approaches, endocardial leads provide low energy thresholds and can be implanted relatively safely. Epicardial pacing systems in patients who previously underwent open heart surgery often meet problems of high pacing thresholds and require a second thoracotomy.4 Cohen et al.,1 who analyzed the long-term outcome of permanent epicardial pacing in paediatric patients, suggested that recent advances in steroid-eluting epicardial leads and the subxiphoid approach had improved pacing and sensing thresholds compared with conventional non-steroid-eluting epicardial leads and the sternotomy or thoracotomy approaches. This patient, after undergoing open-heart surgery three times, had an epicardium with extensive fibrosis and adhesions that for surgical pacing can be risky and challenging. Permanent ventricular pacing via the CS in patients with Fontan circulation has been reported in rare cases either with a conventional lead4,5 or a newly designed CS lead.6,7 Therefore, transvenous pacing using a newly developed CS pacing lead offered an easier and safer solution than epicardial pacing for this patient.
Patients with tricuspid valve disease, receiving tricuspid prosthetic valves, are another patient group raising concern over transvenous endocardial pacing. Alternative pacing through the great cardiac or middle cardiac veins using conventional RV pacing leads has been performed on patients with tricuspid prostheses.8–10 However, the pacing threshold in such cases was high and the procedure was difficult. With the development of pacing leads specially designed for implantation in the CS and the growing experience in CRT, left ventricular pacing has gradually become a reliable and feasible technique for long-term pacing therapy. Specially designed guiding catheters allow for easy engagement of the CS ostium, providing rapid and stable access to the cardiac venous system. The newly developed over-the-wire lead system further improves lead implantation at any location in the cardiac venous system as long as the guide wire can reach the site of choice.
In conclusion, ventricular pacing using a specially designed CRT CS lead is a reasonable and feasible option in selected patients who require permanent pacing but have no RV access.
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References |
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[1] Cohen MI, Bush DM, Vetter VL, et al. Permanent epicardial pacing in pediatric patients: seventeen years of experience and 1200 outpatient visits. Circulation 2001; 103: 2585–90.
[2] Warfield DA, Hayes DL, Hyberger LK, Warnes CA, Danielson GK. Permanent pacing in patients with univentricular heart. Pacing Clin Electrophysiol 1999; 8: 1193–201.
[3] Shah MJ, Nehgme R, Carboni M, Murphy JD. Endocardial atrial pacing lead implantation and midterm follow-up in young patients with sinus node dysfunction after the Fontan procedure. Pacing Clin Electrophysiol 2004; 27: 949–54.[CrossRef][Medline]
[4] Blackburn ME and Gibbs JL. Ventricular pacing from the coronary sinus of a patient with a Fontan circulation. Br Heart J 1993; 70: 578–9.
[5] Rosenthal E, Qureshi SA, Crick JC. Successful long-term ventricular pacing via the coronary sinus after the Fontan operation. Pacing Clin Electrophysiol 1995; 18: 2103–5.[Medline]
[6] Ermis C, Zadeii G, Gupta M, Benditt DG. Trans-aortic His bundle ablation with permanent ventricular pacing via the coronary sinus in L-transposition of great arteries with classic Fontan procedure. J Interv Card Electrophsiol 2002; 7: 257–60.
[7] Fan K and Yung TC. Permanent ventricular pacing from coronary sinus after Fontan operation using newly designed left ventricular lead. J Interv Card Electrophsiol 2002; 7: 89–93.
[8] Bai Y, Strathmore N, Mond H, Grigg L, Hunt D. Permanent ventricular pacing via the great cardiac vein. Pacing Clin Electrophysiol 1994; 17: 678–83.[Medline]
[9] Nguyen LS, Swaroop S, Prejean CA. Pacing in middle cardiac vein in a patient with tricuspid prosthesis. Pacing Clin Electrophysiol 2002; 25: 243–4.[Medline]
[10] Faerestrand S and Ohm OJ. Alternate pacing sites for patients with tricuspid valve prostheses. Pacing Clin Electrophysiol 2002; 25: 234–8.[Medline]
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