Lead placement pacing

Worley SJ, Gohn DC, Pulliam RW (2008) Coronary vein rupture during venoplasty for LV lead placement. Pacing Clin Electrophysiol 31(7) 904-907... 

Gayle DD, Bailey JR, Haistey WK, et al. A novel ultrasound-guided approach to the puncture of the extrathoracic subclavian vein for surgical lead placement. PACE 1996 19 700. 

Furman S. Subclavian puncture for pacemaker lead placement. PACE 1986 9 467. 

Fig. 4.64 Lateral view demonstrating transhepatic lead placement. (Fishberger SB, Camunas J, Rodriguez-Femandez H, et al. Permanent pacemaker lead implantation via the transhepatic route. Pacing Chn Electrophysiol 1996 19(7) 1124-1125, with permission.)...

Fig. 4.68 Atrial lead placement through atriotomy and purseslring suture. Atrium and ventricular electrodes are positioned and the atriotomy is secured. (Westerman GR, Van Devanter SH. Transthoracic transatrial endocardial lead placement for permanent pacing. Ann Thorac Surg 1987 43(4) 445-446, with permission.)...

Fig. 4.69 Atrial lead placement. Insert in the upper right shows atrial endocardial lead being placed through the wall of the right atrial appendage with the tip of the pacemaker lead abutting the endocardial surface. A pursestring suture is placed around the lead at the point of entry. The relationship of the atrial lead is also shown. (Hayes DL, Vhetstra RE, Puga FJ, et al. A novel approach to atrial endocardial pacing. Pacing Clin Electrophysiol 1989 12(1 Pt 1) 125-130, with permission.)...

After venous access, some consideration should be given to the sequence of lead placement. Some operators prefer to place the RV electrode first for emergency RV pacing, should heart block ensue because the heart failure patients commonly have a left bundle branch block and any trauma to the conduction system or right bundle may result in complete heart block. Other operators choose to place the coronary sinus lead first and, if necessary, depend on heart rate support via a temporary transvenous pacemaker placed via the femoral vein. The issue of failure speaks for placing the coronary sinus lead first. Should the procedure fail with unsuccessful left-sided left ventricular lead placement and the patient has already received right-sided electrodes, a pacing system may be left without an indication unless a future second attempt is considered. As more and more systems are placed for a primary prevention indication like MADIT II, this has become less problematic (153). 

Fig. 4.88 A. Guide wire passed into a posterolateral branch of the CS. B. Example of the various angioplasty guide wires for use in over the wire lead placement (from Belott PH Implantation Techniques for Cardiac resynchronization Therapy Barold SS, Mugica J Fifth Decade of Cardiac Pacing. Armonk NY Futura. 2004 pp 18)...

Recently, thoracoscopic approaches, less risky than thoracotomy, have been developed for the placement of left ventricnlar leads (155-157). Still to be resolved are the issues of lead instabihty and unreliable sensing and pacing characteristics. On the horizon, with respect to an epicardial approach, is a percntaneons technique utilizing robotics for left-sided lead placement. 

Westerman GR, Van Devanter SH. Transthoracic transatrial endocardial lead placement for permanent pacing. Ann Thorac Surg 1987 43 445. 

In patients with left bundle branch block, it is advised that right ventricular lead placement be secured before left ventricular lead implantation or coronary sinus osteal localization since traumatic interruption of right bundle branch conduction could lead to the development of catheter-induced complete heart block and the need for urgent ventricular pacing. 

Fig. 7.7 (A) Twelve-lead ECG during pacing demonstrates left bundle-branch block morphology and inferiorly directed mean frontal plane axis, suggesting that the pacing electrode is in the right ventricular outflow tract. (B) Pacing lead placement in the right ventricular apex is indicated by the left bundle branch block morphology and the mean frontal plane superior axis. Notice that the pacemaker does not sense the premature ventricular depolarization (fourth QRS complex in all leads), which indicates that the sensitivity should be increased (by reducing the sensitivity value).

Padeletti L, Purerfellner H, Adler SW, Waller TJ, Harvey M, Horvitz L, Holbrook R, Kempen K, Mugglin A, Hettrick DA. Combined efficacy of atrial septal lead placement and atrial pacing algorithms for prevention of paroxysmal atrial tachyarrhythmia. J Cardiovasc Electrophysiol. 2003 14 1189-1195. 

The presence of LV dyssynchrony and the site of placement of the LV lead are two important determinants of response to CRT. The role of imaging modalities like echocardiography, MRI, and ERNA in measuring LV dyssynchrony and predicting response to CRT has been discussed in detail in the previous section. The site of LV lead placement is also important better outcomes have been noted with lateral LV pacing as compared to anterior LV... 

Dekker AL, Phelps B, Dijkman B, van der Nagel T, van der Veen FH, Geskes GG, Maessen JG. Epicardial left ventricular lead placement for cardiac resynchronization therapy optimal pace site selection with pressure-volume loops. J Thorac Cardiovasc Surg 2004 127 1641-7. 

Bennett et al. reported that atrial activation times were similar when pacing from the CS os, Bachmann s Bnndle or the interatrial septum (30). Of these three options, septal lead placement may be preferable given its relative lack of technical complexity. Indeed, Hermida et al. showed no difference in feasibility and reliability comparing septal and RAA pacing sites, whereas septal pacing was associated with shorter interatrial activation times and reduced left atrial electromechanical delay (36). 

The ventricle or atrium can be paced, depending on where in the coronary sinus the lead is positioned. Figures 18.17-18.19 demonstrate coronary sinus lead placement in the lateral coronary, anterior interventricular, and middle cardiac veins. 

Once a lead has been implanted, it must remain stable (or fixated). The fixation device is either active or passive. Active-fixation leads incorporate corkscrew mechanisms, barbs, or hooks to attach themselves to the myocardium. Passive-fixation leads are held in place with tines that become entangled in the net-like lining (trabeculae) of the heart. Passive-fixation leads generally have better acute pacing and sensing performance but are difficult to remove chronically. Active-fixation leads are easier to remove chronically and have the advantage of unlimited placement sites. Some implanters prefer to use active-fixation leads in the atrium and passive-fixation leads in the ventricle. 

Fig. 7.2 Serial anteroposterior fluoroscopic images taken during transvenous removal of a left-sided dual-chamber implantable cardioverter-defibrillator (ICD) system. After placement of a temporary right-ventricular (RV) pacing system

Pacing leads can be subdivided into a number of groups based on the area of placement and method of stimolation. Leads can be placed either on the epicardium (external surface) of the heart or, by a transvenous route, onto the endocardium (internal surface) of the right heart atrium or ventricle. Epicardial leads are used for permanent pacing in pediatric cases, where size considerations or congmtal defects prevent transvenous placement, and in patients who have undergone tricuspid valve rqilacement (Mitrani et al., 1999). Transvenous placement of the lead is the preferred route in most patients. 

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