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).