LV Lead Implantation Tools: Choices of LV Leads
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This document discusses tools and techniques for left ventricular lead implantation in patients with complex cardiac anatomy: 1. It recommends having backup pacing available and describes approaches for implanting the right ventricular lead first or left ventricular lead first. 2. The six step implant process is outlined as: cannulating the coronary sinus, performing venograms, selecting the target vein and left ventricular lead, placing the leads, measuring the electrical measurements, and removing the delivery system tools. 3. Techniques are provided for overcoming challenges with each step like variable coronary sinus anatomy, dilated right atrium, valves obstructing advancement, and small vessel size. The importance of pre-procedural venography is emphasized for selecting optimal target
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LV Lead Implantation Tools: Choices of LV Leads
- 1. LV lead implantation tools: Management of complex anatomy June 19, 2016 振興醫院 心臟內科 張鴻猷醫師
- 3. 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
- 4. 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
- 5. 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
- 10. MB2 Standard or high takeoffs of the CS Multipurpose Standard or high takeoffs of the CS Curve allows cradling in a medium to large size RA
- 11. Extended Hook Vertical takeoff of CS Use with an inner catheter (Attain Select® II) to reach across a large dilated RA Amplatz Bypasses Eustachian Ridge or Thebesian valve near or blocking CS
- 12. 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
- 13. Autopsied Hearts Large K9 Heart (approximately the size of normal human heart) Heart from MIRACLE study patient
- 15. 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 0.3 0 0.5 1 1.5 2 2.5 HF non-HF Height(inCm)
- 16. Tough Coronary Sinus Cannulation Contrast flushing test at LAO in low RA Change sheath of different curve Use coronary angiography catheter (for example: Amplatz) Deflectable EP catheter Late phase coronary angiography
- 17. Cannulate CS Advancing Deflectable Cath. CathSheath LAO: 50o Images compliments of Dr. Randy Lieberman
- 19. Valves obstructing catheter or lead advancement Tricuspid annulus Coronary sinus Thebesian valve Membranous valve covering postero-inferior aspect of CS ostium In 10-20% of cases, can impede CS cannulation
- 23. 2. Perform CS Venograms
- 24. 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
- 26. 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
- 27. Complication of VenogramComplication of Venogram
- 28. Tamponade
- 29. Total occlusion of Coronary Sinus?Total occlusion of Coronary Sinus?
- 30. 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
- 31. Collateral filling of cardiac veins
- 32. Narrowing or stenotic CS
- 33. 3. Select Target Vein & LV Lead
- 34. Cardiac Veins Anatomy A. Lateral (marginal) cardiac vein B. Postero-lateral cardiac vein C. Posterior cardiac vein D. Middle cardiac vein E. Great cardiac veinA B C D E Target: Left ventricular free wall A B C D E LAO View Veins in the 2-5 o’clock positions (LAO) are the best
- 35. RAO & LAO Venogram
- 36. 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
- 37. Lead PlacementLead Placement AP view LAO 40º view LAO 40º view shows goodLAO 40º view shows good separation between theseparation between the RV and LV leadsRV and LV leads AP view shows RVAP view shows RV placement nearplacement near interventricular septuminterventricular septum Images compliments of Dr. Daniel Gras
- 38. 4. Place the LV lead
- 39. 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
- 40. 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
- 42. 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 smaller veins with moderate to great tortuosity Attain OTW Model 4194 6.2 Fr (2.0 mm) True bipolar Easy trackability and pushability in medium to large veins Attain Starfix Model 4195 5 Fr (1.7 mm) Unipolar Placement in a variety of vein positions with active fixation (deployable lobes) Attain Ability Model 4196 4 Fr (1.3 mm) Bipolar (dual electrode) Improved trackability into smaller veins Programmable repositioning of pacing vectors
- 43. 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
- 44. 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.
- 45. Attain® Performa™ FamilyAttain® Performa™ Family Quadripolar Short-space dipole Special design S-shape curve
- 46. 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 mm 1.3 mm 21 mm
- 48. 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
- 49. Performa Straight 4398Performa Straight 4398 Small vessel size Acute vessel curvature Ensure lead is deep seated and wedged Trackability is better than 4298 and 4598 due to the distal shape
- 50. Attain Performa 4298Attain Performa 4298 Medium vessel size Moderate vessel curvature Fixation force most similar to 4196 due to similar construction at proximal cant
- 51. 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® Plus 4296 (5.3 F, canted) Attain Ability 4196 (4 F, canted) Attain Ability Straight 4396 (4 F, straight with tines) Different Curves vs Cardiac VeinsDifferent Curves vs Cardiac Veins
- 52. Coronary venous stents for lead retention
- 53. 5. Take Electrical Measurements
- 54. LVLV LeadLead Threshold TestThreshold Test R-wave: ≥ 5.0 mV Voltage threshold @ 0.5 ms: ≤ 3.0 V Impedance @ 5 V/0.5 ms : 250 - 1000 Ohms 10 V for phrenic nerve
- 55. 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
- 56. ECG Capture TemplatesECG Capture Templates RV stimulationRV stimulation BiventricularBiventricular stimulationstimulation (LV + RV)(LV + RV) Intrinsic RhythmIntrinsic Rhythm LV stimulationLV stimulation RVRV LVLV PSAPSA ++ -- RVRV LVLV PSAPSA RVRV LVLV PSAPSA -- ++ ++ -- --
- 57. 6. Remove Delivery System Tools
- 58. Prepare for Catheter RemovalPrepare for Catheter Removal 1. Insert a stylet into the lead. 2. Remove the valve. 3. Place towels for support.
- 59. 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!
- 60. 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
- 61. Conclusion
- 62. Thank you forThank you for your attention !!!your attention !!!
Editor's Notes
- #3: What to say: Before starting the implant procedure, we will review some general guidelines and tips/tricks of the procedure. What to do: What to ask:
- #4: What to say: “When using any Attain® lead as part of a biventricular pacing system, decide which ventricular lead to use first. Consider the ease of coronary sinus cannulation and the need for backup pacing. When a left ventricular lead is implanted first: It may be easier to cannulate the coronary sinus without other leads already implanted. Additional hospital equipment may be necessary to provide backup pacing. When a right ventricular lead is implanted first: A right ventricular lead may be used to provide backup pacing. It may be more difficult to cannulate the coronary sinus with a right ventricular lead already implanted.” What to do: What to ask:
- #15: Notice the angulation of the coronary sinus takeoff change as the heart dilates.
- #20: What may be a good tool to use here? What catheter helps you get past the thebesian valve? Amplatz.
- #23: Non-compliance BC, stiff guidewire with hydrophilic coating
- #25: The Attain Model 6215 Venogram Balloon 80 cm. 6 Fr. 0.025 inch inner lumen diameter A venogram is recorded for future reference regarding lead placement. Generally an AP, LAO and RAO view are recorded to fully understand: Venous anatomy Access to left lateral wall The size and tortuosity of the veins A venogram is critical to the success of the Left Heart Lead implant! Provides a “road map” of the venous anatomy. Two or more views are necessary to capture more than just an “aerial” view; additional views give the third dimension (tell you about the “bumps” in the road). The venogram image of the patient’s anatomy assists in determining the LV lead choice.
- #29: Low pressure system, fat pad, not easily tamponade
- #38: What to say: “Fluoroscopy in both AP and LAO 40 views were reviewed to verify the final locations of the leads. Multiple views provide different and informative observations of the lead placement. The AP view shows the RV placement near the inter ventricular septum, whereas the LAO view shows good separation between the RV and LV leads (as depicted with the arrow).” What to do: What to ask:
- #41: NOTES: The Attain Select II delivery catheter can be used to: Cannulate CS ostium through an outer CS cannulation catheter Sub-select target cardiac vein Deliver 4 Fr (1.3 mm) lead Cannulate CS Ostium When inside a fixed shape or deflectable outer catheter, the Attain Select II delivery catheter has increased reach for coronary sinus cannulation The soft distal tip on the Attain Select II delivery catheter is designed to lower trauma risk during coronary sinus cannulation Sub-selection Double-braided shaft with 1:1 torque Soft, concentric tip for smooth telescoping Angled distal tip to aid in sub-selection Deliver 4 Fr (1.3 mm) Lead The Attain Select II delivery catheter is the smallest sub-selection catheter on the market, that is capable of delivering a 4 Fr (1.3 mm) lead directly to a branch vein Attain® OTW 4193 is compatible with the Attain Select II delivery catheter
- #43: Attain 4193: 4 Fr (1.33 mm), unipolar lead Lead lengths – 78 cm and 88 cm Steroid - Dexamethasone Sodium Phosphate Purpose: Smaller veins with moderate to great tortuosity Attain 4194: 6 Fr (2.0 mm), bipolar lead Lead lengths – 78 cm and 88 cm Steroid - Dexamethasone Sodium Phosphate Purpose: Medium to large veins with moderate tortuosity Attain StarFix 4195: 5 Fr (1.67 mm), unipolar lead Lead lengths – 78 cm, 88 cm, and 103 cm Steroid Eluting - Beclomethasone Purpose: Increased stability with deployable lobes Attain Ability 4196: 4 Fr (1.3 mm), bipolar (dual electrode) lead Lead lengths – 78 cm and 88 cm Fixation – Compound cants Steroid – Dexamethasone acetate Purpose: Programmable repositioning with the ability to get into a small vein
- #45: Biffi, M et al. Occurrence of phrenic nerve stimulation in cardiac resynchronization therapy patietns: the role of left ventricular lead type and placement site. Europace 2012.
- #47: No Compromising Flexibility or Reverse Polarity Benefits Medtronic Viva Quad XT, Viva Quad S, Brava Quad CRT-D manuals. Demmer W. Vector Express Performance Results. Medtronic Data on File. January 2013.
- #55: Answer: 1. (Dual Ventricular Unipolar); 2. (Dual Ventricular Bipolar); 3. Shared Common Ring Bipolar Bipolar Lead 2188 Unipolar Leads 4189, 2187 Dual Ventricular Unipolar Dual Ventricular Bipolar Shared Common Ring Bipolar The Y adaptor implementation also results in additional ventricular lead polarity options: Dual Ventricular Unipolar: If both the RV and LV lead are unipolar leads, both leads pace tip to can. Dual Ventricular Bipolar: If both the RV and LV lead are bipolar leads, both leads pace tip to ring (Medtronic currently only has one LV lead that is bipolar the Attain Model 2188). Shared Common Ring Bipolar: This is the most typical case. If the RV lead is bipolar and and LV lead is unipolar, the LV lead will share the ring of the RV lead. This essentially provides all of the benefits of bipolar LV pacing, in that the sensing vector remains within the heart, reducing the chance for sensing of muscle artifact.
- #57: The Analyzer connections for collecting ECG templates. Recommend obtaining strips using the vectors normally used during follow up and via a 12 lead, if possible. This may require attachment of skin electrodes prior to the start of the implant. A few things to keep in mind about LV thresholds during implant: During lead positioning, thresholds should be assessed in a unipolar manner. Final thresholds should be taken using the intended pacing configuration after device connection. For a bipolar RV lead, the configuration will be LV common ring. Note: It is recommended that you obtain both an EKG and an EGM template for every pacing configuration when implanting an InSync Model 8040 device. Please look at the printed Analyzer strip and not the telemetry on the programmer when you are verifying capture. Always label the strips and what lead was used at the time it is obtained
- #59: What to say: “Three steps are recommended in preparation for catheter removal: Insert a stylet into the lead (picture on the left). Remove the valve (picture on the right). Place towels for support (picture on the right).” What to ask: “What do you think is the next step?” What to do:
- #60: What to do: Start the video by positioning the mouse-cursor over the image and clicking once. To stop or restart the video at anytime, click once on the image. What to say: “During the catheter removal process, begin slitting through the center of the thin walled section (side opposite of the handle) of the hub. Always track the angle of the hub during the removal process. User should ALWAYS watch their hands during the slitting process and have someone else watch fluoroscopy. Key Usage Tips: Keep thumb positioned in center of thumb rest Keep slitter blade in center of catheter hub Additional force required at hub/catheter junction - keep slitter blade parallel to guide catheter center line and axis Do not “rock” the slitter through the hub If need to re-start slitting, start a new cut” What to ask: Video filename: SLITTING NEW HUB.mpg
- #61: What to say: “Other Tips: Hold the slitter and lead in one hand (preferably the right hand). Keep slitter blade parallel w/axis of catheter. If using Red/Green Slitter, rock the slitter gently through the hub if necessary. Do not push forward with the right hand when slitting. Hold the right hand stable. Manipulate the guide catheter to remove as much residual torque as possible. To help secure lead in slitter grooves, grip proximal end of lead in hand that is holding the slitter. This may help prevent the lead from coming out of the slitter grooves during slitting.” What to do: What to ask: