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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Figures