CRT
Coronary sinus stenting for the stabilization of left ventricular lead during resynchronization therapy
aw Lenarczyk1
ski21 First Department of Cardiology, Silesian Medical School, Silesian Center for Heart Diseases, Zabrze, Szpitalna 2, Poland; 2 Third Department of Cardiology, Silesian Medical School, Silesian Center for Heart Diseases, Zabrze, Szpitalna 2, Poland
Manuscript submitted 5 September 2005. Accepted after revision 12 February 2006.
* Corresponding author. Tel: +48 32 271 34 14; fax: +48 32 271 76 92. E-mail address: elfizab{at}poczta.onet.pl
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Abstract |
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We report on two patients treated with cardiac resynchronization therapy, in whom early (intra-operatively, 64-year-old man) and late (4 months post-operatively, 57-year-old woman) instability of the left ventricular (LV) lead occurred. In order to stabilize the electrodes, stents were deployed in both patients within the coronary sinus, into the space between the lead and the wall of the vein effectively pinning the lead to the wall. During 3 and 5 months of follow-up, the electrodes remained stable and allowed for successful resynchronization in both cases. Stenting within the coronary sinus seems to be a safe method for LV lead stabilization, which can substantially increase the success rate of resynchronization therapy. This new approach, although promising, has to prove its safety and should not be practised routinely until long-term follow-up data are available.
Key Words: Resynchronization therapy, Stenting, Coronary sinus
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Introduction |
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Cardiac resynchronization therapy (CRT) is a widely accepted therapeutic modality in a selected group of patients with heart failure. Positive effects not only on quality of life and functional capacity, but also on survival, have been documented for this therapy with the addition of an implantable cardioverter-defibrillator and recently for CRT alone.1
–4 The broad implementation of CRT into clinical practice is hampered by complexity of the implantation procedure, especially the difficulties met during the implantation of the left ventricular (LV) lead. One of the common problems observed is late dislocation of the LV electrode, with resultant abrupt loss of capture and ineffectiveness of biventricular pacing. This complication has been reported in as many as 5% of all CRT patients.1–5 Moreover, inability to reach a stable position of the lead within the chosen branch of the coronary sinus during implantation has been described previously as one of the causes leading to failure of the procedure.6 Taking into account the growing impact of resynchronization therapy in the heart failure population and the anticipated expansion of the indications for CRT, it would be valuable to find solutions which could reduce these limitations. We report on two patients treated with CRT, in whom the early and late instability of the lead could be successfully obviated by means of stenting within the coronary sinus (Figures 1 and 2).
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Case 1 |
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A 64-year-old man with dilated cardiomyopathy after myocardial infarction and with severe heart failure, resistant to optimal pharmacotherapy, was admitted to our institution in order to undergo resynchronization therapy. The patient presented with functional New York Heart Association (NYHA) class III, standard 12-lead electrocardiogram fulfilled the criteria of the left bundle branch block with QRS duration of 155 ms. Transthoracic echocardiography revealed a LV ejection fraction of 24% and the signs of significant inter- and intra-ventricular mechanical dyssynchrony. The right ventricular CapSureFix Novus 5076 (Medtronic, Minneapolis, MN, USA) and atrial electrode CapSureFix 5568 (Medtronic) were implanted in a standard way into the apex of the right ventricle and right atrial appendage, respectively, using the cut-down technique on the cephalic vein. Thereafter, the left heart delivery system Attain LDS 6216A (Medtronic) was introduced into the coronary sinus via puncture of the subclavian vein. After angiography to visualize the detailed anatomy of the coronary sinus, an attempt to implant the unipolar, polyurethane-insulated lead Attain LV 2187 with the body diameter of 6.2 F (Medtronic) into the lateral vein was undertaken. Because of inability to cannulate the vessel with this lead, and failed attempts to cannulate a second, more anteriorly oriented branch, the unipolar polyurethane-insulated over-the-wire lead Attain OTW 4193, with body diameter of 4.0 F (Medtronic) was used. Although the second electrode could be introduced into the lateral vein successfully, no stable fixation of the lead inside the branch was possible. Shortly after implantation, several episodes of lead dislocation occurred, which were related to the motion of the heart or the diaphragm. Repeated manoeuvres were needed to reposition the electrode into the proper area. Because of lead instability, a decision was made to stabilize the lead with a stent causing entrapment of LV electrode in the lateral vein. After the withdrawal of the left heart delivery system and guide catheter used previously to introduce the lead, the subclavian vein was punctured and the coronary sinus was cannulated with a second catheter Attain MB2 (Medtronic), which was introduced separately over the guidewire close to the previously inserted lead. The angioplasty guidewire Pilot 150 (Guidant, Santa Clara, CA, USA) and, subsequently, bare metal, cobalt–chromium stent MicroDriver 2.5x8 mm (Medtronic) were introduced into the lateral vein, parallel to the lead. The diameter of the stent exceeded the diameter of the target vessel, as assessed by quantitative angiography, by 0.5 mm. The stent was deployed 2 cm distally to the vessel take-off, into the space between the lead and the wall of the vein, using the pressure of 8.0 bar and inflation time of 45 s, fixing the electrode (Figure 1). After implantation, angiography was performed, which showed unrestricted perfusion of the targeted vein and a stable position of the lead. The procedure was completed with implantation of the pacemaker InSync III (Medtronic). The procedure duration was 160 min, fluoroscopy time 43 min. Follow-up period of 3 months was uneventful for the patient, the routine checkups of the pacemaker revealed the proper stimulation, sensing, and impedance of both leads, with the threshold of the LV lead <2.0 V/0.4 ms.
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Case 2 |
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A 57-year-old woman with idiopathic dilated cardiomyopathy and the signs of congestive heart failure was admitted to our centre to undergo CRT. The patient was in functional NYHA class III, 12-lead electrocardiogram revealed left bundle branch block pattern and QRS duration of 160 ms. Transthoracic echocardiography demonstrated an LV ejection fraction of 27% and advanced inter- and intra-ventricular dyssynchrony. Three leads, including LV unipolar, polyurethane-coated lead Attain OTW 4193, with the body diameter of 4.0 F (Medtronic), and pacemaker InSync III (Medtronic), were successfully implanted. During 3 months of follow-up, the patient improved clinically to NYHA class II, and the maximum oxygen consumption measured during stress test increased from 16 to 21 mL/kg/min. Four months after the implantation, however, the patient was re-admitted, complaining of progressive fatigue. The pacemaker follow-up and chest radiograph revealed dislocation of the LV lead to the right atrium. A decision was taken to repeat the implantation procedure. After the dislocated lead was re-inserted into the lateral vein using a pre-shaped stylet and guidewire, the left heart delivery system Attain LDS 6216A (Medtronic) was introduced by puncture of the subclavian vein, and cannulation of the coronary sinus ostium was performed. Coronary sinus angiography was undertaken with the balloon catheter Attain 6215 (Medtronic) to show its anatomy. Taking into consideration the broad lateral vein, no alternative pacing sites, and to avoid future re-interventions in the case of repeated dislodgment, a decision was taken to perform coronary sinus stenting. The angioplasty guidewire Pilot 50 (Guidant) and, subsequently, the bare metal, stainless steel stent Invastent Volo 3.0x7 mm (InvaTec, Brescia, Italy) were introduced into the target vessel through the guide catheter positioned in coronary sinus ostium. Stent diameter exceeded the diameter of the vein by 0.5 mm. The stent was positioned distally to the orifice of the lateral vein, between the lead and the vascular wall. The pressure used equalled 8.0 bar, inflation time 45 s (Figure 2). Angiography at the end of the procedure revealed unobstructed contrast flow through the lateral vein. The pacemaker InSync III (Medtronic) was re-used. Procedure duration was 135 min and the fluoroscopy time was 29 min. During 5 months of observation, the patient improved clinically, routine pacemaker follow-up showed effective biventricular stimulation, with the threshold of LV lead not exceeding 3.0 V/0.4 ms.
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Discussion |
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Vein stenting has previously been described as a method for the treatment of peripheral venous narrowings in the patients with renal venous thrombosis or obstructed caval veins.7
,8 It has also gained acceptance as a treatment option in patients with obstructed coronary artery bypass grafts.9,10 However, only limited data exist on stenting within the coronary sinus. Van Gelder et al.11 reported on the stenting technique used for a narrowed postero-lateral branch of the coronary sinus in one patient, which allowed for the successful implantation of LV lead. All the previously published work on vein stenting reported the use of this method as a means to achieve patency of an obstructed vessel. Our paper reports on stenting within the coronary sinus in two patients, which was performed in non-stenotic veins, in order to stabilize pacing leads prone to dislocation. The authors have adopted the strategy, in which acute stenting was performed when multiple dislocations of at least two models of leads had occurred (or only one model could be implanted successfully, but was unstable), and there were no alternative vessels accessible for lead insertion. In the case of late dislocation in the patient without alternative coronary sinus branches, stenting was performed just after the first dislocation. This procedure was implemented to avoid potential future repositioning, which could possess a particular risk for the patient with a low ejection fraction and signs of heart failure. The angiography performed intra-operatively showed the unrestricted perfusion through the target vessels in both cases. After the implantation procedure, apart from routine pharmacotherapy used in patients with the heart failure, both were treated with acetylsalicylic acid in a daily dose of 150 mg, no anticoagulants or other antithrombotics were administered. To prevent the occlusion of the major veins, we positioned the stents in the lateral branches, out of the main lumen of the coronary sinus and used the stents with the diameter exceeding the diameter of veins by 0.5 mm. This method has confirmed its short-to-medium term safety and efficacy in our two patients, no intra- or peri-operative complications were noted. The procedure duration (mean 147.5 min) and fluoroscopy time (mean 36.0 min), although longer than those for standard implantations performed in our institution (mean procedure duration 133.1 min, fluoroscopy time 30.5 min), remained acceptable for the patient and the operators. Furthermore, this technique allowed for a long-term stabilization of the LV lead, which would probably be impossible in 2 of 31 (6.4%) patients treated with CRT in our centre. Considering stenting as an alternative to the epicardial surgical approach in the group with difficult anatomy, one should bear in mind several potential drawbacks of this method. The long-term performance of LV leads, which have been entrapped with stents, is unknown; the possibility of mechanical damage of the lead insulation related to motion between the lead and the stent should be considered. Stenting can also limit the ability of lead removal in the case of diaphragmatic stimulation or lead infection, exposing a high-risk patient to a surgical procedure. Taking into consideration these potentially dangerous disadvantages, this new approach should not be practised routinely, until long-term follow-up data are available. Our preliminary data suggest that stenting of a coronary sinus is a safe and efficient method of stabilization of a LV lead in the cases of repeated or late dislocation in patients undergoing CRT. However, the long-term efficacy and safety of stenting should be evaluated in further studies.
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References |
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[1] Abraham WT, Fisher WG, Smith AL, et al. MIRACLE Study Group. Multicenter InSync Randomized Clinical Evaluation. Cardiac resynchronization in chronic heart failure. N Engl J Med 2002; 346: 1902–5.
[2] Cazeau S, Leclercq C, Lavergne T, et al. Multisite Stimulation in Cardiomyopathies (MUSTIC) Study Investigators. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med 2001; 344: 873–80.
[3] Bristow MR, Saxon LA, Boehmer J, et al. Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure (COMPANION) Investigtors. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140–50.
[4] Cleland JGF, Daubert JC, Erdman E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352: 1539–49.
[5] Strickberger SA, Conti J, Daoud EG, et al. Patient selection for cardiac resynchronization. Circulation 2005; 111: 2146–50.
[6] Tse HF, Yu C, Lee KL, et al. Initial clinical experience with a new self-retaining left ventricular lead for permanent left ventricular pacing. Pacing Clin Electrophysiol 2000; 23: 1738–40.[Medline]
[7] Pfammatter T, Williams DM, Lane KL, Campbell DA Jr, Cho KJ. Suprahepatic caval anastomotic stenosis complicating orthotopic liver transplantation: treatment with percutaneous transluminal angioplasty, wallstent placement or both. Am J Roentgenol 1997; 168: 477–80.
[8] Ward CJB, Mullins CE, Nihill MR, Grifka RG, Vick W. Use of intravascular stents in systemic venous and systemic venous baffle obstructions. Circulation 1995; 92: 2948–54.
[9] Urban P, Sigwart U, Golf S, Kaufman U, Sadeghi H, Kappenberger L. Intravascular stenting for stenosis of aortocoronary venous bypass grafts. J Am Coll Cardiol 1989; 13: 1085–91.[Abstract]
[10] Mehl JK, Schieman G, Dittrich H, Buchbinder M. Emergent saphenous vein graft stenting for acute occlusion during percutaneous transluminal coronary angioplasty. Catheter Cardiovasc Diagn 1990; 21: 266–70.[ISI][Medline]
[11] Van Gelder BM, Meijer A, Basting P, Hendrix G, Bracke FA. Successful implantation of a coronary sinus lead after stenting of a coronary vein stenosis. Pacing Clin Electrophysiol 2003; 26: 1904–6.[CrossRef][Medline]
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