Six year experience of transvenous left ventricular lead implantation for permanent biventricular pacing in patients with advanced heart failure: technical aspects

Abstract

Background: Biventricular pacing has been proposed as an adjuvant to optimal medical treatment in patients with drug refractory heart failure caused by chronic left ventricular systolic dysfunction and intraventricular conduction delay.

Objective: To assess the technical feasibility and long term results (over six years) of transverse left ventricular pacing with the lead inserted into a tributary vein of the coronary sinus.

Subjects: From August 1994 to February 2000, left ventricular lead implantation was attempted in 116 patients who were eligible for biventricular pacing (mean (SD) age 67 (9) years, New York Heart Association (NYHA) functional class III/IV, left ventricular ejection fraction 22 (6)%, QRS duration 185 (26) ms).

Results: The overall implantation success rate was 88% (n = 102). A learning curve was indicated by a progressive increase in success from 61% early on to 98% in the last year. The mean pacing threshold was 1.1 (0.7) V/0.5 ms at the time of implantation and increased slightly up to 1.9 (0.9) V/0.5 ms at the end of the follow up period (15 (13) months). The rate of acute and delayed left ventricular lead dislodgement decreased from 30% in the early years to 11% after 1999. During follow up, 19 patients required reoperation for delayed lead dislodgement or increase in left ventricular pacing threshold (n = 15), phrenic nerve stimulation (n = 3), or infection (n = 3).

Conclusions: Transverse left ventricular pacing through the coronary sinus is feasible and safe. The rate of implantation failure and of lead related problems has decreased greatly with increasing experience and with improvements in the equipment.

Figure 1

Left ventricular lead position and implant pacing thresholds.

Figure 2

Change in implantation rate over time.

Figure 3

In this example there is a large lateral vein in which a thick conventional lead could easily be introduced. LV, lateral vein; RA, right atrial lead; RV, right ventricular lead; LV, left ventricular lead.

Figure 4

In this coronary sinus angiogram (left) there was a large posterolateral vein. However, the angle it makes with the coronary sinus may make it difficult to reach. In this case a very thin lead, with side wire technology, could be introduced into the vein (chest x ray on the right). LV, left ventricular lead; PLV, posterolateral vein; RA, right atrial lead; RV, right ventricular lead.

Figure 5

It can be seen on this coronary sinus angiogram (left) that there was no lateral or posterolateral vein, so that a choice had to be made between the great cardiac vein and the mid-cardiac vein. In this case the left ventricular lead was placed in the mid-cardiac vein, as can be seen on the chest x ray (right). GCV, great cardiac vein; LV, left ventricular lead; MCV, mid-cardiac vein; RA, right atrial lead; RV, right ventricular lead.