HK-IN-PACE

Heart Rhythm Refresher Course 2013

Module 1 Cardiac Pacing:
Concepts and Practice
Implantation Techniques: From venous
access to Lead implantation
Dr. K Chan
Ruttonjee and Tang Shiu Kin Hospitals

Transvenous CRT implant

1.Venous access
1.Cannulation of coronary sinus
2.Coronary sinus venogram
3.Left ventricular leads implantation
4.Removal of implant tools
5.Troubleshooting

Venous access
1. Subclavian vein puncture
Puncture site: Junctional of medial and mid 3 rd of
clavical aiming towards sternal notch

2. Axillary vein puncture

Puncture site: 1 or 2 cm medial and parallel to the
deltopectoral groove @ 1 FB below coracoid process

3. Cephalic vein cutdown

Landmark: Deltopectoral groove fat pad

Surface Anatomy

Heart Rhythm 2006;3:366-

Pocket Creation Pre-pectoral

plane

Pre-pectoral plane: 3 features

1.Shiny/white prepectoral fascia
2.Painful
3.Fasciculation with electrocautery
Heart 2009;95;259-264

Anatomy of Subclavian/
Axillary/ Cephalic Venous
System

Heart Rhythm 2006;3:366-

Fluroscopic Anatomy of
Subclavian/ Axillary/ Cephalic
veins

Heart 2009;95;259-264

Subclavian/Axillary Vein
Puncture
Suclavian

Axillary

Heart Rhythm 2006;3:366-

Axillary Puncture

Heart 2009;95;259-264

Cephalic Cutdown

Heart 2009;95;259-264

Pros and Cons of Different Venous Access

Routes

Heart 2009;95;259-264

Retained Guidewire
Technique

Insertion of guide-wire and

sheath

Heart 2009;95;259-264

Anatomy of Coronay Sinus

Os of Coronar
Sinus

Coronary Venous Anatomy

CM Yu. Cardiac Resynchronization Therapy. 2nd Ed

Cannulation of the Coronary Sinus

Techniques of CS
Cannulation
1. Direct guiding catheter cannulation
2. Guidewire (0.035) guided
cannulation
3. EP Catheter guided cannulation

Thebasian Vale &

Eustachian Ridge Block CS
assess

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

When the tip of catheter

starts up too high above CS

Couterclockwise torque directs the tip downward & to the left / away fro

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

When the tip of catheter

starts up too low below CS

Couterclockwise torque also directs the tip downward & away from CS

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

CS Cannulation Technique
The Eustachian ridge and Thebesian
valve form a pocket that catches the tip
Techniques:
1.Advance the guiding catheter
across the tricuspid annulus
into RV
2. Slightly withdraw
3. Apply counter-clockwise torque to
direct the guiding catheter
posteriorly into CS os

Choice of Appropriate Guiding

Catheter according to anatomy

In dilated hearts, large proximal cure carries the tip of catheter acro
RA/Eustachian Ridge and lifts the tip above the os of CS
Proximal Curve lying against the lateral wall of RA/ Eustachian Ridge
provides extra support and stability

Choice of Guiding Catheters

Boston Scientific
& Medtronic
Multipurpose

Medtronic Attain
Extended Hook

Guidant Extended Hook

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Biotronik Guiding Catheters

Diagnostic Catheter Technique

Multi
Purpose
(MP)

Amplatz left

Left internal
mammary
(LIMA)

Boston Scientific Guiding

Catheters

St Jude Cardiac Positioning

System

Medtronic Attain Command Catheters

Standard Anatomy
Multipurpose (MP)

Dilated Heart/ superior

CS takeoff:
Extended Hook Extra
Large
Amplatz

Deep seating required/

tapered shafts:
Straight/ MP Extra
MB2 Extra

R sided implant:
MP Right
Straight

Medtronic Attain Select

Subselection catheter
CS with Sigmoidal
takeoff
Telescoping a
subselection catheter in
a guiding catheter to
create desirable shape
Subslection of CS
branches
90/ 130 degrees
Outer diameter 7.1Fr
Inner diameer 5.7Fr

Combination of Telescoping Guiding

Catheters to tailor desirable shapes to
faciliate CS cannulation

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Guidewire guided CS
Cannulation

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Sub-selection catheter
guided CS cannulation

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Coronary Sinus Venogram

Purposes of CS Venogram

Pre-shot to grossly assess CS size before balloon

inflation (avoid balloon dissection of CS)

Assess CS Venous Anatomy for selection of LV lead

(Size & implantation site)

Acquire Orthogonal views to assist side branch

cannulation

Assess anatomical variations (Valves/

Angulation/Persistent LSVC/Thrombosis )

RAO Venogram

LAO Venogram

Occlusive CS Venogram

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

CS Venogram - AP

CS Venogram - LAO

CS Venogram - RAO
Posterior Cardiac
Vein

Selecting vein for CRT lead

placement

F
B

C
D D

A. Postero-lateral
cardiac vein
B. Lateral cardiac vein
C. Posterior cardiac
vein
D. Middle cardiac vein
F. Anterior cardiac
vein

Which CS branch to use?

General rule of thumb:
Good capture threshold
Good stability
Non-apical (preferably basal/lateral)
Greatest separation between RV and LV tip
Avoid infarcted myocardium if possible
No phrenic nerve stimulation (or pacing threshold
<< diaphragmatic capture
threshold)
Narrow paced QRS duration ?

LV Lead positioned in the apical region

Associated with unfavorable outcom
Choose non-apical position

LV Lead Implantation

Medtronic Attain
LV lead family

Biotronik LV Leads Corox

Boston Scientific LV Leads

A complete set of support tools and LV leads including ACUITYTM Spiral with a
1,35mm (4F) tapered LV lead tip profile and a unique 3D helical fixation for predictable
and successful CRT implants
8 different types of RAPIDO CS-Guiding Catheters
4 different types of EASYTRAK and ACUITY Left Ventricular Leads
EASYTRAK 2
Bipolar
Steroid-eluting
Passive fixation

EASYTRAK 3
Bipolar
Steroid-eluting
Helix memory
shape fixation

ACUITY Steerable
Bipolar
3D Tip Control

ACUITY Spiral
Unipolar
1,35 mm (4F) Tapered
Lead Tip Profile

Boston Scientific Acuity Spiral LV Le

St Jude QuickFlex Leads

St Jude

St Jude Quadripolar LV Lead

St Jude Quadripolar LV Lead

Summary of Left Ventricular

Leads

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

LV Lead implantation
techniques

Guidewire assisted LV Lead

Implant

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Buddy wire technique

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Subselection Catheter
assisted
LV
Lead
Implant
Advance and pull-back

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Subselection Catheter
assisted
LV Lead Implantation

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Telescoping Hockey Stick

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Telescoping subselection
guding catheter assisted LV
lead implant

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Balloon Venoplasty assisted

LV Lead Implant

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Anchoring balloon in an upstream venous branch

PACE 2009;32:1577-81

Things to check before

closure

Lead impedance/Sensing/Pacing thresholds

(check different pacing configurations/ watch out for anodal capture)

Recheck diaphragmatic pacing/phrenic nerve

stimulation (10V)
Recheck electrical and radiological stability
with breathing maneuvers
Ensure adequate/ but not excessive lead laxity

Removal of implant tools

Withdrawal of guiding catheter out

of CS os with wire/stylet support
before slitting

Dropping of guiding catheter into RA can dislodge the LV Lead

Need to withdraw guiding catheter out of CS os before slitting

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Maintain curvature in the

stylet upon guiding catheter
withdrawal
Straight stylet can dislodge LV lead

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Maintain a proximal curve in the LV Lead

catheter

Maintain a proximal curve/ laxity in LV lead

upon guiding catheter withdrawal to avoid
dislodging the LV lead

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Maintain laxity of LV lead

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Slitting the Sheaths

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Slitting Technique

Forehand holding
the hub should
remain steady
Correct Technique Maintaining
hub in line with slitter
Force of pulling should be
Coaxial with the lead/guiding

Incorrect Technique - Pulling catheter

shaft at angle to slitter

LV Lead Implant
Complications

Vascular complications/ bleeding

Pneumothorax
Air emoblism/ pulmonary embolism
Coronary venous dissection/perforation
Cardiac tamponade
Lead related complications
Valvular injury
Infection
Cardiac/ neurological complications

Troubleshootings
Difficult LV Lead Implantation
Absence of subclavian/axillary venous access/ thrombosis

1.

2.
3.

4.

5.
6.

Subclavian balloon venoplasty

Epicardial/ Endocardial LV Lead implantation
Iliac implant Approach

Eustachian ridge/ Thebasian valve

Use guiding with different curvatures

Valve of Vieussens

Use telescoping deflectable guiding/0.035guide wire to nudge

open
Tortuous/sigmoidal CS takeoff

Use telescoping subselection catheter to change curvature

Use anchoring balloon

CS venous stenosis

Balloon venous angioplasty

Difficulty advancing the lead

Buddy wire/ Subselection catheter

Anchoring balloon
Goose-neck Snare/Tretrograde wiring technique (Seth Worley)

Iliac implant Technique

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Valve of Vieussens
1. Gently attempt to pass
wire; valve may
open/close
2. Or, insert 0.035 wire /
deflectable catheter to
gently nudge open
3. Do proof shot
4. Track the guide
catheter over
deflectable catheter
5. Repeat proof shot thru
guide

Troubleshootings
High LV lead capture thresholds
Diaphragmatic pacing/Phrenic nerve
stimulation
Solutions:
Repositioning of LV lead (advance or withdrawal)
Try threshold test with different pulse width config
Try bipolar vs unipolar thresholds
Electrical repositioning: changing pacing
configurations (e.g. LV tip/ring to RV coil/ RV ring)

Troubleshooting
Easy LV Lead dislodgement:
1.Active fixation lead inside CS
2.Stenting of LV lead inside CS
(problem with future lead extraction)
3.Impingement lead technique (putting
an extra LV lead in CS for fixation)

Troubleshooting
What if transvenous LV lead
implantation fails:
1.Epicardial LV Lead implantation
2.Endocardial LV Lead implantation

Epicardial LV Lead Implant

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Novel CRT Implant

Techniques

CT Fluoroscopy Fusion

CardioGuide 3D System:
Optimize LV Lead Implant
Select preferred target site and choose LV lead

Navigate real-time in fluoro

Obtain anatomical information about target & match best lead

Detect exactly where lead is & how far from target
83
Medtronic Confidential

Magnetic Navigation - Stereotaxi

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Ellenbogen et al. Clinical Cardiac Pacing, Defibrillation, and Resynchronization

Thank you
Compliments
Presentation materials kindly provided
by
Medtronic
Biotronik
St. Jude
Boston Scientific