Inadvertent Lead Malposition in the Left Ventricle during Permanent Ventricular Pacing about One Case

Inadvertent Lead Malposition in Left Ventricle is a rare and underdiagnosed incident, which may occur during implantation of cardiac electronic devices and may remain asymptomatic. We reported the case of a 71-year-old man who was implanted with a ventricular single-chamber pacemaker for a slow atrial fibrillation with syncope and whose routine transthoracic echocardiography 23 months after implantation displayed a malposition of the pacemaker lead into the Left Ventricle through a patent foramen oval. The patient was asymptomatic. The electrocardiogram showed right bundle branch block QRS-paced morphology with a positive QRS pattern in V1, a median paced QRS axis on the frontal plane at -120°, a Precordial transition on V5. At the lateral Chest X-ray the lead curved backwards to the spine. Given the age of this old patient who already received oral anticoagulant for Atrial Fibrillation and the Lead malposition discovered 23 months after pacemaker’s implantation, we decided to maintain the lead in LV and continue anticoagulation.

Echocardiographic mapping of left ventricular resynchronization during cardiac resynchronization therapy procedures

Background Cardiac resynchronization therapy （CRT） is an effective electrical therapy for patients with moderate to severe heart failure and cardiac dyssynchrony. This study aimed to investigate the degree of acute left ventricular （LV） resynchronization with biventricular pacing （BVP） at different LV sites and to examine the feasibility of performing transthoracic echocardiography （TTE） to quantify acute LV resynchronization during CRT procedure. Methods Fourteen patients with NYHA Class Ⅲ-Ⅳ heart failure, LV ejection fraction 〈35%, QRS duration 〉120 ms and septal-lateral delay （SLD） 〉60 ms on tissue Doppler imaging （TDI）, underwent CRT implant. TDI was obtained from three apical views during BVP at each accessible LV site and SLD during BVP was derived. Synchronicity gain index （Sg） by SLD was defined as （I＋（SLD at baseline - SLD at BVP）/SLD at baseline）. Results Seventy-two sites were studied. Positive resynchronization （R＋, Sg〉1） was found in 42 （58%） sites. R＋ was more likely in posterior or lateral than anterior LV sites （66% vs. 36%, P 〈0.001）. Concordance of empirical LV lead implantation sites and sites with R＋ was 50% （7/14）. Conclusions The degree of acute LV resynchronizaUon by BVP depends on LV lead location and empirical implantation of LV lead results in only 50% concordance with R＋. Performing l-rE during CRT implantation is feasible to identify LV sites with positive resynchronization.

Utility of echocardiographic tissue synchronization imaging to redirect left ventricular epicardial lead placement for cardiac resynchronization therapy

Background Cardiac resynchronization therapy （CRT） with biventricular pacing has demonstrated cardiac function improvement for treating congestive heart failure （HF）. It has been documented that the placement of the left ventricular lead at the longest contraction delay segment has the optimal CRT benefit, This study described follow-up to surgical techniques for CRT as a viable alternative for patients with heart failure. Methods Between April 2007 and June 2012, a total of 14 consecutive heart failure patients with New York Heart Association （NYHA） Class Ill-IV underwent left ventricular epicardial lead placements via surgical approach. There were eight males and six females, aged 36 to 79 years （（59.6±9.2） years）. The mean left ventricular ejection fraction （LVEF） was （33.6±7.4）%. All patients were treated with left ventricular systolic dyssynchrony and underwent left ventricular epicardial lead placements via a surgical approach. Tissue Doppler imaging （TDI） and intraoperative transesophageal echocardiography were used to assess changes in left heart function and dyssynchronic parameters. Also, echo was used to select the best site for left ventricular epicardial lead placement. Results Left ventricular epicardial leads were successfully implanted in the posterior or lateral epicardial wall without serious complications in all patients. All patients had reduction in NYHA score from Ⅲ-Ⅳ preoperatively to Ⅱ-Ⅲ postoperatively. The left ventricular end-diastolic diameter （LVEDD） decreased from （67.9±12.7） mm to （61.2±7.1） mm （P〈0.05）, and LVEF increased from （33.6±7.4）% to （42.2±8.8）% （P〈0.05）. Left ventricular intraventricular dyssynchrony index decreased from （148.4±31.6） ms to （57.3±23.8） ms （P〈0.05）. Conclusions Minimally invasive surgical placement of the left ventricular epicardial lead is feasible, safe, and efficient. TDI can guide the epicardial lead placement to the ideal tar qet location.

Use of the Attain Select Ⅱ catheter delivery system to improve left ventricular lead implantation in cardiac resynchronization therapy

Background Despite technical advances in tools used to facilitate implantation of cardiac resynchronization therapy （CRT） devices, there are many hurdles related mainly to the variation in the anatomy of the coronary veins. One such difficulty is the presence of a very sharply-angulated or tortuous of the lateral or posterolateral cardiac vein.Methods Totally 44 patients, 28 males and 16 females, with congestive heart failure and intraventricular conduction delay were studied retrospectively. There were 23 patients who had left ventricular （LV） lead implantation using standard techniques and equipment. For the other 21 patients with LV lead implantation we used the Attain Select Ⅱ catheter delivery system. The patients were seen every 3-6 months for 12 months and the efficacy of the primary procedure, LV lead implantation time, procedure and fluoroscopy time and the complications associated with the two techniques were evaluated.Results There were no significant differences in the age, gender, New York Heart Association （NYHA） functional class,ischemic etiology, QRS duration, left ventricular ejection fraction, left ventricular end-diastolic diameter, left ventricular end-systolic diameter and LV dyssynchrony between the two groups. The LV lead implantation time, procedure time and fluoroscopy time were significantly shorter in the group using the Attain Select Ⅱ catheter delivery system; LV lead implantation time from （51-7） minutes to （40±7） minutes （P ＜0.001）, procedure time from （143±17） minutes to （124±18）minutes （P=0.001）, and fluoroscopy time from （45±7） minutes to （35±6） minutes （P＜0.001）. A successful procedure of LV lead implantation was significantly improved from 17/23 （74%） patients using the standard techniques and equipment, to 20/21 （95.3%） patients using the Attain Select Ⅱ catheter delivery system （P=0.06）Conclusion It is feasible and safe to implant LV leads through the coronary sinus using the Attain Select Ⅱ catheter delivery system.