Case 5
A 78-year-old female with a past medical history of paroxysmal non-valvular atrial fibrillation, non-ischemic cardiomyopathy status post primary prevention CRT-D 3 years prior was noted to have elevated RV and LV thresholds with early battery depletion. She underwent placement of a His bundle pacing lead. Unfortunately, the threshold following the procedure was elevated. As she had responded quite well to CRT previously, the recently placed His lead was removed and another unsuccessful attempt at CS lead placement was made and aborted due to high thresholds. At this point, procedure was transitioned to placement of an LV endocardial lead. LV endocardial lead placement was performed without significant variation from the previously described procedure. On follow-up 2 years after the procedure she was doing well without any complications, NYHA class II, but no repeat evaluation of EF.
Discussion:
Placement of a traditional LV lead in the CS has a number of anatomic and technical limitations including inadequate lateral or posterolateral branches, venous occlusion, phrenic nerve stimulation, or high pacing thresholds. 8 Additionally, 20-40% of patients do not respond to biventricular pacing .7 Given these issues, alternative sites for LV lead placement have been proposed. Epicardial placement has a higher periprocedural morbidity and some concerns regarding long term durability.8,16
Physiologic pacing techniques, such as His bundle pacing and Left bundle branch (LBB) pacing are also a viable alternative in select patients. His bundle is the most commonly used physiologic approach, and there have been many studies evaluating the feasibility and clinical efficacy of the technique. However, there are some drawbacks to His bundle pacing including difficulty finding the His signal, damage to the His bundle during implantation of the lead, high or unstable pacing thresholds, low R wave amplitudes or large atrial signals which can complicate pacing, and block distal to the pacing site in the conduction system. However, there is some evidence to suggest that His bundle pacing may be an alternative in CRT non-responders.20-30
LBB pacing is another physiologic approach to pacing but is less common and newer than His bundle pacing. There is some evidence to support the feasibility of this approach as an alternative to traditional CRT.31,32 However, there are some complications that include LV perforation, injury to the right bundle, septal coronary artery injury, and tricuspid valve entrapment.32
Other novel techniques include “wireless” LV lead stimulation as described in the WiSE-CRT trial and SELECT-LV study where a patient undergoes a wireless LV electrode triggered by subcutaneous ultrasound that is coordinated with an RV lead. However, this requires a pre-screening process, a complex procedure, and had non-negligible complication rates of stroke, electrode embolization, pericardial effusion, and infection.33
LV endocardial lead placement via the interatrial septa was initially described in 1998 and techniques have advanced since then.34 An alternative technique to the one used in this series is known as the Jurdham procedure and involves placement of the LV endocardial lead from the femoral vein and extracting the proximal end into the subclavian pocket.35 LV endocardial pacing has hemodynamic advantages to epicardial pacing as the entirety of the endocardial LV is available for optimal lead placement, whereas with epicardial pacing there are limitations due to venous anatomy, coronary anatomy, and phrenic nerve location.36,37 However, there are some issues to consider with this approach, including exacerbation of mitral regurgitation, the need for lifelong anticoagulation, and technical challenges including the need to repeat the transseptal process if the apparatus comes out of the LA. There are also potentially challenging scenarios that may arise that currently lack a clear resolution such as what to do if the LV lead needs to be extracted or if a LV assist device is needed. One patient in this series developed severe mitral regurgitation from lead impingement on the leaflets and has been planned for extraction with the goal of attempting physiologic pacing. There is limited data on the outcomes of LV endocardial lead extraction, but there are some limited case reports and case series highlighting some approaches to extraction.38, 39
One of the biggest concerns with LV endocardial leads is the risk of stroke. This was not observed in our small series, however, we only consider LV endocardial lead placement in patients who already have a lifelong indication for warfarin, and have been on warfarin for at least one year without complications.
This series describes an underutilized approach that mitigates some of the anatomical challenges of LV endocardial lead placement using combined superior and inferior access to snare and carry a wire from the subclavian vein transseptally. Overall the procedure was well tolerated and effective. Of note, all patients had previously been on lifelong anticoagulation with warfarin and had contraindications to both CS and epicardial lead placement. While there are currently several alternatives to traditional coronary sinus leads, a complete toolbox for placement of a CRT system should include endocardial LV lead placement.
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