LV lead implantation tools: Management of complex

anatomy

June 19, 2016振興醫院 心臟內科 張鴻猷醫師

Getting Started

Getting Started

• Backup pacing should be readily available (LBBB + RBBB = complete heart block)

• RV lead first Can be used to provide backup pacing May also provide a landmark for coronary sinus Helps to visualize tricuspid valve, which can help locate CS ostium May be more difficult to cannulate the CS with the lead implanted

• LV lead first May be easier to cannulate the CS Additional method may be necessary to provide backup pacing May be more likely to dislodge when going to place RV lead

Getting Started

• Use preferred method to access subclavian vein

• Use lead introducer ( 9.0 Fr) to maintain access

• Prepare all delivery system components before procedure begins– Flush all lumens with heparinized saline– Flush and test the venogram balloon catheter – Wet the guide wire with heparinized saline

Implant Procedure

Six-Step Implant Process

1. Cannulate coronary sinus

2. Perform venograms

3. Select target vein and leads

4. Place leads

5. Measure final electrical measurements

6. Remove implant tools

1. Cannulate CS

Attain Command Family

RAPIDO Cut-Away Family

MB2Standard or high takeoffs of the CS

MultipurposeStandard or high takeoffs of the CS

Curve allows cradling in a medium to large size RA

Extended HookVertical takeoff of CS

Use with an inner catheter (Attain Select® II) to reach across a large dilated RA

AmplatzBypasses Eustachian Ridge or Thebesian valve near or blocking CS

Common obstacles to a CRT case

• Variable CS ostium location• Dilated right atrium• Valves obstructing catheter or lead

advancement• Severe kinking of the vein• Small vessel size of CS

Best solution: Preprocedural venography

Autopsied HeartsLarge K9 Heart

(approximately the size of normal human heart)

Heart from MIRACLE study patient

Anatomy of The CS –Variations in Height over the RA Floor

• HF pts tended to have higher CS origin than non-HF pts (p<0.001)

• Height of CS origin slightly more variable in HF pts

1.2

0.6

2.2

1.4

0.30

0.5

1

1.5

2

2.5

HF non-HFHe

ight

(in

Cm)

Tough Coronary Sinus Cannulation

Contrast flushing test at LAO in low RAChange sheath of different curveUse coronary angiography catheter (for

example: Amplatz)Deflectable EP catheterLate phase coronary angiography

Cannulate CS

Advancing Deflectable Cath.

CathSheath

LAO: 50oImages compliments of Dr. Randy Lieberman

Valves obstructing catheter or lead advancement

Tricuspid annulus

Coronary sinus

Thebesian valveMembranous valve covering postero-inferior aspect of CS ostium

In 10-20% of cases, can impede CS cannulation

2. Perform CS Venograms

Perform Venogram: tipsPerform Venogram: tips• Consider tracking balloon over a guide wire

• Balloon can be inflated and deflated several times

• Proof shot first

• Prolonged contrast solution (10-20cc) for retrograde filling of vessels, two or more views

Why perform a venogram?

Provide a Visualization of Cardiac Venous Anatomy

Increase Chance of Successful Lead Placement

Insight into size and tortuosity of veins

KNOWN PROBLEMS:-venous trauma (advancing balloon too far)-vein dissection-added risk to patients with renal insufficiency

Complication of VenogramComplication of Venogram

Tamponade

Total occlusion of Coronary Sinus?Total occlusion of Coronary Sinus?

Importance of Multiple Views

Notice the origin of the lateral target vessel

LAO View RAO View

Images compliments of Dr. Seth Worley

Target Lateral Branch

Target Lateral Branch

Collateral filling of cardiac veins

Narrowing or stenotic CS

3. Select Target Vein & LV Lead

Cardiac Veins Anatomy

A. Lateral (marginal) cardiac veinB. Postero-lateral cardiac veinC. Posterior cardiac veinD. Middle cardiac veinE. Great cardiac veinA

BC

D

E

Target: Left ventricular free wall

A

BCD

E

LAO View

Veins in the 2-5 o’clock positions (LAO) are the best

RAO & LAO Venogram

Prioritize Several Target Veins on the Left Postero-Lateral Free Wall

Select vessels that:• Maximize separation between RV and LV

leads• Avoid infarcted myocardium and phrenic

nerve stimulation• Are small enough to securely wedge lead

tip

Lead PlacementLead Placement

AP view LAO 40º view

LAO 40º view shows good LAO 40º view shows good separation between the separation between the

RV and LV leadsRV and LV leads

AP view shows RV AP view shows RV placement near placement near

interventricular septuminterventricular septum

Images compliments of Dr. Daniel Gras

4. Place the LV lead

LV Lead DeliveryLV Lead Delivery

• Select LV lead: Bipolar or unipolar, Curved or straight

• Select delivery system: Stylet driven, Over the wire, Inner sheath

• Similar technique as PCI

• Position the guidewire as distal as possible

• Exchange more stiff wire if more support is needed

• Advance sheath for added support

• Buddy wire technique for acute angulation

Branch vein delivery system

Size:• 7.1 Fr (2.4 mm) Out Diameter• 5.7 Fr (1.9 mm) Inner Diameter• 65 cm length• 90°or 130°Function:• Branch vein selection• Delivery 4 Fr (1.3 mm) LV lead

Select the LV LeadSelect the LV Lead

Attain StarFix®

Attain Ability®

4193

4194

Leads Lead Body Size

Polarity Designed for:

Attain® OTW Model 4193

4 Fr (1.3 mm)

Unipolar Placement in smallerveins with moderate

to great tortuosity

Attain OTW Model 4194

6.2 Fr (2.0 mm)

True bipolar

Easy trackability andpushability in medium to

large veins

Attain Starfix

Model 41955 Fr (1.7

mm)Unipolar Placement in a variety of

vein positions with active fixation (deployable lobes)

Attain Ability

Model 41964 Fr (1.3

mm)Bipolar(dual

electrode)

Improved trackability into smaller veins

Programmable repositioning of pacing

vectors

Attain StarFixAttain StarFix®®

• First active fixation left-heart lead

• More placement options– Vein sizes– Vein locations

• Soft, polyurethane deployable lobes

• 5 Fr lead body, 5.3 Fr electrode with tip seal

Compromise due to Phrenic Nerve Stimulation

Phrenic nerve stimulation can occur in all LV locations and tends to occur more often in

mid-lateral regions where the lead is often targeted for

placement

1. Biffi, M et al. Europace 2012.

Attain® Performa™ FamilyAttain® Performa™ Family

Quadripolar

Short-spacedipole

Special design

S-shape curve

16 Programmable Vectors + VectorExpress™

Programming Flexibility and Reverse Polarity Benefits1,2

1. Medtronic Attain Performa 4598, 4298, 4398 LV Lead manuals.2. Demmer W. VectorExpress Performance Results. Medtronic data on file. January 2013.

21 mm1.3 mm

21 mm

Different CurvesDifferent Curves

Performa S 4598Performa S 4598

Medium to large vessel size

Fixation and tracking through vessel will be different than double cant shape

– Curves oppose each other

– Three curves

Performa Straight 4398Performa Straight 4398

Small vessel size Acute vessel

curvatureEnsure lead is deep

seated and wedged Trackability is

better than 4298 and 4598 due to the distal shape

Attain Performa 4298Attain Performa 4298Medium vessel sizeModerate vessel

curvatureFixation force most

similar to 4196 due to similar construction at proximal cant

Attain® Performa™ 4598

(5.3 F, S- shape)

Attain Performa 4298

(5.3 F, canted)

Attain Performa 4398

(5.3 F, straight with tines)

Large,Low

tortuosity vessels

Small,High

tortuosity vessels

Attain StarFix®

4195 (5 F, deployable

lobes)

Attain Ability® Plus4296

(5.3 F, canted)

Attain Ability4196

(4 F, canted)

Attain Ability Straight

4396(4 F, straight

with tines)

Different Curves vs Cardiac VeinsDifferent Curves vs Cardiac Veins

Coronary venous stents for lead retention

5. Take Electrical Measurements

LV Lead Threshold TestLV Lead Threshold Test

R-wave: ≥ 5.0 mVVoltage threshold @ 0.5 ms: ≤ 3.0 VImpedance @ 5 V/0.5 ms : 250 - 1000 Ohms10 V for phrenic nerve

RV Lead TestRV Lead Test

• R-wave: ≥ 5 mV• Threshold @ 0.5 ms: ≤ 1 V• Impedance @ 5 V/0.5 ms: 250 –1000 Ohms

RA Lead TestRA Lead Test• R-wave: ≥ 2 mV• Threshold @ 0.5 ms: ≤ 1.5 V• Impedance @ 5 V/0.5 ms: 250 –1000 Ohms

ECG Capture TemplatesECG Capture Templates

RV stimulationRV stimulation

Biventricular Biventricular stimulationstimulation

(LV + RV)(LV + RV)

Intrinsic RhythmIntrinsic Rhythm

LV stimulationLV stimulationRVRV

LVLV

PSAPSA ++ --

RVRV

LVLVPSAPSA

RVRV

LVLV

PSAPSA --

++

++

----

6. Remove Delivery System Tools

Prepare for Catheter RemovalPrepare for Catheter Removal

1. Insert a stylet into the lead. 2. Remove the valve.3. Place towels for support.

Slitting the Guiding CatheterSlitting the Guiding Catheter Keep slitter blade in

center of hub and parallel to guide catheter

ALWAYS watch hands during slitting process!

Slitting the Guiding CatheterSlitting the Guiding Catheter

Keep slitter blade parallel with guide catheter hub

Turn your body away from patient, pull catheter in single smooth motion toward your LEFT hip

Conclusion

Thank you for Thank you for your attention !!!your attention !!!