Abstract 470 <strong>Cardiac Resynchronisation Therapy in Difficult Coronary Sinus Anatomy: A Staged Approach Including Epimyocardial Implantation of Left Ventricular Lead Increases Success Rate to 100 Percent</strong>   

Z Kardiol 94: Suppl 2 (2005)

Cardiac Resynchronisation Therapy in Difficult Coronary Sinus Anatomy: A Staged Approach Including Epimyocardial Implantation of Left Ventricular Lead Increases Success Rate to 100 Percent

L. Obergassel¹, B. Küpper², B. Borchert³, T. Lawrenz³, H. Warnecke², D. Meyer zu Vilsendorf³, Ch. Stellbrink³

¹Klinik f. Kardiologie und intern. Intensivmedizin, Städt. Kliniken Bielefeld, Klinikum Mitte, Bielefeld, BusinessLogic.Land; ²Schüchtermann Klinik, Herzzentrum Osnabrück-Bad Rothenfelde, Bad Rothenfelde; ³Klinik f. Kardiologie und intern. Intensivmedizin, Städt. Kliniken Bielefeld - Klinikum Mitte, Bielefeld;

Background: Transvenous implantation (TVI) of left ventricular (LV) leads is the standard approach for cardiac resynchronisation therapy (CRT). However, anatomical conditions prevent the TVI in few patients (pts). Therefore we studied the acute and long term results of a staged approach including the epicardial implantation of LV leads in failed TVI..
Methods: Fifty-five consecutive pts (mean age 66 ± 11 y; NYHA: 3.2 ± 0.5; LV – EF: 24 ± 8%; QRS - duration: 172 ± 25 ms) underwent TVI of a CRT device. In case of an unsuccessful transvenous attempt the LV lead was implanted epimyocardially after median sternotomy in a second surgical procedure aiming for a gentle posterolateral lead position. Clinical follow up was carried out after 3, 6, 9 and 12 months. CS - leads: Guidant Easytrak 1, 2 and 3, Medtronic Attain 2187, 4193, 4194 as well as Capsure Epi 4965, 4968.
Results: The TVI was successful in 52 pts (95 %). The preoperatively defined target vein (TV) was reached in 48 (87%) pts. The epicardial LV lead implantation was carried out in 3 pts without alternative TV. The posterolateral target area was reached in these 3 pts. In one patient epicardial lead positioning was combined with coronary bypass surgery. The LV epicardial lead measurements (stimulation threshold = 1,1/1,4/0,8 V/0.5 ms and R - wave - signal = 10,5/6,2/11,0 mV) of the 3 hybrid - pts were stable after 10.7 ± 8.7 months. The significant clinical improvement (Table) with CRT was not different between the two groups (TVI and EPI). No complications occurred.

Table: Recovery of cardiac heart failure after transvenous (TVI) and epimyocardial (EPI) implantation of the CRT – device

NYHA before implantation
NYHA after 6 months
P
TVI, N = 52
3.2 ± 0.5
1.6 ± 0.6
0.0001
EPI, N = 3
3.7 ± 0.6
2.0 ± 1.0
0.008
P
n . s.
n. s.

Conclusion: A staged TVI – epicardial - approach is a safe and effective strategy for CRT in difficult CS - anatomy for transvenous LV lead implantation. In our patient cohort this approach led to an increase of CRT applicability from 95 % to 100 % and can be combined with coronary bypass surgery.

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