13. Utility of Active Fixation Lead in Unstable Left Ventricular Lead Positions in the Coronary Sinus for Left Ventricular Stimulation

Published on 26/02/2015 by admin

Filed under Cardiovascular

Last modified 22/04/2025

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History

The patient had recurrent hospital admissions for heart failure despite optimal tolerable medical therapy. He had a left ventricular ejection fraction of 25% and mechanical dyssynchrony on tissue Doppler echocardiogram. He also had documented nonsustained ventricular tachycardia and paroxysmal atrial fibrillation on Holter monitoring.

Current Medications

The patient was taking warfarin 0.125 mcg/daily, furosemide 40 mg twice daily, carvedilol 12.5 mg twice daily, aldactone 25 mg daily, digoxin 0.125 mg daily, simvastatin 20 mg daily, and valsartan 80 mg daily.

Current Symptoms

Recurrent admissions for heart failure. Significantly breathless at mild exertion (New York Heart Association class III).

Physical Examination

Laboratory Data

Focused Clinical Questions and Discussion Points

Question

How frequently is a left ventricular lead with an active fixation mechanism required to pace the left ventricle?

Discussion

A left ventricular lead with some form of active fixation mechanism is required to overcome anatomic peculiarity, unstable lead position, and a circumscribed area of optimal pacing threshold without phrenic nerve stimulation in 12% of patients.3
image

FIGURE 13-1 Subselective coronary sinus venogram in left anterior oblique (A) and right anterior oblique (B). Note that the size of the distal coronary sinus branch is bigger than the size of the guiding catheter.

Question

Why was an active fixation lead chosen for this patient?

Discussion

The coronary sinus venogram (Figure 13-1) revealed a huge single posterolateral branch, the caliber of which exceeded even the biggest size of left-sided lead currently available. The trajectory of the posterolateral branch was straight and lacking in any degree of tortuosity that may help hold a conventional left ventricular lead in position after the support is removed. Therefore the chances of lead dislodgment if a standard left ventricular lead is used is relatively high.

Question

Why was a conventional left ventricular–specific active fixation lead not used in this patient?

Discussion

The currently available left ventricular–specific active fixation lead fixes itself indirectly by opposing the fixation lobes at the sides of the lead to the coronary sinus wall. This will promote tissue ingrowth from the coronary sinus side wall into the lead and therefore complicate future lead removal.2,4 The size of the lead within the coronary sinus and tissue ingrowth also will lead to thrombosis of the coronary sinus branch,3 a potential problem because the patient has a solitary coronary sinus branch if he is in need of left ventricular lead replacements in the future. Furthermore, this lead is a unipolar lead, thus limiting its use if electronic repositioning is required.
By using a 3830 lead, stability is achieved without compromising the coronary sinus if future use is required. Because the lead is bipolar, electronic repositioning can be performed easily if needed.

Question

How are the performances of the 3830 lead in the coronary sinus?

Discussion

The 3830 lead has an acceptable pacing threshold and impedance at implant and over a mean period of 8.1 months in 36 patients in whom it was implanted. No acute or long-term complications occurred. The pacing threshold and impedance remained stable at 8 months.1

Plan of Action

The patient was still symptomatic despite optimal medical therapy, with nonsustained ventricular tachycardia and evidence of mechanical dyssynchrony on a tissue Doppler echocardiogram; therefore the decision to implant a cardiac resynchronization therapy defibrillator was made.

Intervention

The right ventricular lead was implanted conventionally. The coronary sinus was engaged with a standard coronary sinus conventional sheath. An inner catheter was used in a telescoping fashion to extend the reach of the sheath into the subselected coronary sinus branch. A venogram was then performed in two oblique views (Figure 13-2).
A Medtronic 3830 active fixation lead was then delivered to its target site via the telescoping sheath. At the target site, the lead is rotated clockwise two to three times to fix the lead to the underlying myocardium. Pacing parameters were then tested accordingly, and on completion, the telescoping and guiding sheaths were conventionally removed.
image

FIGURE 13-2 A 90-degree subselection catheter was used in telescoping fashion to guide the direction of the 3830 lead (A). Once the 3830 lead was in position, the lead was fixated by rotating the lead clockwise for two to three turns. The position of the lead was then checked in the left anterior oblique (B) and right anterior oblique views (C).

image

FIGURE 13-3 Final position of the leads in left anterior oblique (A) and right anterior oblique (B) views. Despite the size of the coronary sinus branch being bigger than the size of the lead, the lead retained its position at its fixed location.

Outcome

The implantation was completed successfully with acceptable pacing parameters without any complications (Figure 13-3). Follow-up at 1 month, 3 months, and 6 months did not show any significant parameter changes.

Selected References

1. Aziz A.F.A., Hussin A., Khelae S.K. et al. Active fixation in the coronary sinus for left ventricular stimulation: an alternative method in improving left sided lead stability and overcoming phrenic nerve stimulation. Heart Rhythm. 2012;5(Suppl):S490.

2. Baranowski B., Yerkey M., Dresing T. et al. Fibrotic tissue growth into the extendable lobes of an active fixation coronary sinus lead can complicate extraction. Pacing Clin Electrophysiol. 2011;34:e64–e65.

3. Luedorff G., Kranig W., Grove R. et al. Improved success rate of cardiac resynchronization therapy implant by employing an active fixation coronary sinus lead. Europace. 2010;12:825–829.

4. Maytin M., Carrillo R.G., Baltodano P. et al. Multicenter experience with transvenous lead extraction of active fixation coronary sinus leads. Pacing Clin Electrophysiol. 2012;35:641–647.

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