A successful placement of the left ventricular lead for the cardiac resynchronization device using the orthodromic snare technique: clinical case

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Abstract

Background: The main aim of Cardiac Resynchronization Therapy (CRT) is a positive response of the patient, particularly, reduction of the symptoms and improvement of the heart contractility, that can be reached in 50–70% of patients. The possibility of appropriate positioning the left ventricular (LV) lead is of great importance for the response to CRT. Certain instruments and technical approaches are used for the placement of the LV lead. Here, we describe the use of the orthodromic snare technique, which is quite rare in practice, but allows one to overcome some anatomical obstacles.

Clinical case description: Patient A., suffering from the heart failure with a low ejection fraction and left bundle branch block, was admitted to the hospital for CRT implantation. Before the operation, all the necessary routine instrumental and laboratory diagnostics was performed. During the operation, venography of the cardiac veins revealed unsuitability of the lateral cardiac vein for the placement of the LV lead due to its very small diameter. The posterolateral vein was suitable for the LV lead implantation but still had some anatomical difficulties: an acute angle of inflow and local stenosis in the proximal segment. During the procedure, the following techniques were used without success: positioning the LV lead by a simple translational movement forward, a subselective catheter, introduction of several coronary guides in order to smooth out the acute angle of inflow. These circumstances warranted the use of the orthodromic snare technique for a successful LV lead placement.

Conclusion: This clinical case illustrates the possibility of a safe and effective use of the orthodromic snare technique for LV lead implantation. Such anatomical difficulties as a small diameter, acute angle of inflow, local stenosis have also been illustrated and discussed.

About the authors

Oleg L. Dubrovin

Federal Center for Cardiovascular Surgery (Chelyabinsk)

Author for correspondence.
Email: doldubrovin@gmail.com
ORCID iD: 0000-0001-9601-4674
SPIN-code: 3889-3003
http://ritmcardio.ru

MD

Russian Federation, 60-101 Universitetskaya Naberegnaya, 454128, Chelyzbinsk

Pavel L. Shugaev

Federal Center for Cardiovascular Surgery (Chelyabinsk)

Email: doc.shugaev@gmail.com
SPIN-code: 7293-8980

MD, Cand. Sci. (Med.)

Russian Federation, Chelyzbinsk

References

  1. Sieniewicz BJ, Gould J, Porter B, et al. Understanding non-response to cardiac resynchronisation therapy: common problems and potential solutions. Heart Failure Rewies. 2019;24(1):41–54. doi: 10.1007/s10741-018-9734-8
  2. Leyva F, Nisam S, Auricchio A. 20 Years of cardiac resynchronization therapy. J Am Coll Cardiol. 2014; 64(10):1047–1058. doi: 10.1016/j.jacc.2014.06.1178
  3. Singh JP, Klein HU, Huang DT, et al. Left ventricular lead position and clinical outcome in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT) Trial. Circulation. 2011;123(11):1159–1166. doi: 10.1161/CIRCULATIONAHA.110.000646
  4. Stoia MA, Istratoaie S, Pop S, et al. The importance of lead positioning to improve clinical outcomes in cardiac resynchronization therapy. In: Cardiac Diseases and Interventions in 21st Century; December 11th, 2018. doi: 10.5772/intechopen.85488
  5. Pothineni NV, Supple GE. Navigating challenging left ventricular lead placements for cardiac resynchronization therapy. J Innov Cardiac Rhythm Manage. 2020;11(5):4107–4117. doi: 10.19102/icrm.2020.110505

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2. Fig. 1. Contrasting the cardiac veins during the operation (right anterior oblique projection, 30°): 1 — filiform lateral cardiac vein; 2 — anterolateral cardiac vein, very narrow within 1.5–2 cm from the vein orifice; 3 — sharp flexion in the proximal part of the posterolateral cardiac vein; 4 — a defect of filling in the posterolateral cardiac vein, its intensity changing with the heart cycle.

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3. Fig. 2. Positioning the left ventricular lead delivery system into the coronary sinus. Passage of the coronary guidewire into the posterolateral vein (right anterior oblique projection, 30°): 1 — coronary guidewire has been introduced into the posterolateral vein with the help of a subselective catheter (2). The guidewire went through the collateral vein into the middle cardiac vein and returned in a retrograde manner to the great cardiac vein; 2 — the left ventricular lead delivery system with a subselective catheter inside. The tip of the subselective catheter was localized in the orifice of the posterolateral vein. It is remarkable, that during the attempts of pushing the left ventricular lead along the guidewire, the subselective catheter fell out of the posterolateral vein orifice (panel 2б); 3 — the left ventricular lead, that was passed along the guidewire.

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4. Fig. 3. Passage of the left ventricular lead into the posterolateral cardiac vein (right anterior oblique projection, 30°): 1 — coronary guidewire is in the posterolateral cardiac vein and is going through the collateral to the middle cardiac vein; 2 — the second left ventricular lead delivery system was positioned in the great cardiac vein. Within the second delivery system, the goose neck snare was introduced. The X-ray shadow of the snare overlaps with the shadow of the ascending part of the guidewire in the great cardiac vein; 3 — the most distal part of the guidewire folded in the upper part of the great cardiac vein and descending back to the coronary sinus ostium (in the 3-rd panel, the capture of the guidewire by the snare is shown); 4 — the goose neck snare is in the second lead delivery system (in panel 3а, the snare is relaxed, in panel 3б, the snare is tightened, the guidewire was captured with the formation of a closed loop, going through the posterolateral cardiac vein, collateral vein and middle cardiac vein); 5 — the distal tip of the left ventricular lead (in panel 3а — the lead tip is in the proximal part of the posterolateral vein, in panel 3б — the lead tip is in the distal part of the posterolateral vein).

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5. Fig. 4. The right ventricular lead and the left ventricular lead it the end of the operation (left anterior oblique, 30°): 1 — the distal tip of the left ventricular lead is in the middle part of the lateral ventricle wall; 2 — the distal tip of the right ventricular lead is in the heart apex.

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Copyright (c) 2021 Dubrovin O.L., Shugaev P.L.

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