Methods:
Five patients with an indication for CRT, on life-long warfarin for
other indications, with relative contraindications to epicardial lead
placement elected to undergo addition of an LV endocardial lead (Table
1). All patients were offered this procedure as an alternative to
surgical LV epicardial lead placement, and most of these patients
underwent the procedure prior to the widespread use of physiologic
pacing. All the procedures were done in either the cardiac operating
room or the electrophysiology lab under general anesthesia or monitored
anesthesia care.
All patients underwent the following general procedure with some minor
variations detailed below. All patients had a device prior to the index
procedure.
First, the prior pocket was opened and a new axillary venous access was
obtained. A femoral venous access site was also obtained in the right
common femoral vein (CFV). A 10 or 11 Fr peel away sheath was advanced
over the left subclavian wire. An Amplatz Gooseneck snare system was
then introduced via the axillary sheath and advanced into the right
atrium (RA) through a long Medtronic (Dublin, Ireland) peel away sheath
(c304, the deflectable His bundle delivery tool). An SL-0 or SL-1 sheath
and dilator were advanced over a wire from the femoral vein into the
SVC. The gooseneck snare was placed over the SL sheath. Then, a
Brockenbrough transseptal needle was advanced through the femoral SL
sheath (Figure 1A) and a transseptal puncture was performed with
guidance from either transesophageal echocardiography or intracardiac
echocardiography along with fluoroscopy. Once the transseptal needle was
in the left atrium, the snare was tightened at the dilator/sheath
interface and the dilator, femoral sheath, and snare were advanced into
the LA (Figure 1B). This carried the axillary peel-away sheath into the
LA. Once in the LA, the snare was freed from the femoral sheath (Figure
1C) and removed leaving the axillary sheath in the LA (Figure 1D). Next,
an active fixation pacing lead (Medtronic 5076 or the equivalent) was
advanced through the deflectable sheath (Figure 1E), across the mitral
valve and fixed on the LV endocardial surface (Figure 1F). Lead
placement and capture were confirmed, sheaths were peeled away and the
pocket was closed in the standard fashion. Follow-up chest X-ray to
confirm lead placement prior to discharge (Figure 2).20,21 Pre and post Electrocardiograms (ECGs) were
obtained with expected shortening of QRS complex (Figure 3).