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Left ventricular lead implantation assisted by magnetic navigation in a patient with a persistent left superior vena cava
International Journal of Cardiology 116 (2007) e15 – e17 www.elsevier.com/locate/ijcard
Letter to the Editor
Left ventricular lead implantation assisted by magnetic navigation in a patient with a persistent left superior vena cava Máximo Rivero-Ayerza ⁎, Yves van Belle, Joris Mekel, Luc J. Jordaens Erasmus MC, Rotterdam, The Netherlands Received 25 July 2006; accepted 4 August 2006 Available online 13 November 2006
Abstract In a woman with a persistent left superior vena cava and a dilated coronary sinus, a right-sided biventricular ICD implantation was performed assisted by remote magnetic navigation. Intra-cardiac echocardiography was helpful in locating the coronary sinus os. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiac resynchronization therapy; Persistent left superior vena cava; Magnetic navigation; Heart failure
1. Introduction A magnetic navigation system has been designed with the purpose of allowing remote steering of dedicated guidewires. In this way it becomes possible to reach areas or access vessels that would otherwise be difficult to get to by conventional means. This system has proven to be useful in assisting conventional CRT device implantations [1]. We present the case of a patient with a dilated cardiomyopathy and a persistent left superior vena cava (LSVC). Magnetic navigation (Niobe™ Stereotaxis, St. Louis, MO, USA) allowed successful implantation of a LV pacing lead within a lateral coronary sinus (CS) side branch. 2. Case presentation A 37 year-old female with a Turner syndrome and standard indications for cardiac resynchronization therapy (CRT) was scheduled for implantation of a biventricular ICD device. A CT scan showed a persistent LSVC communicating
⁎ Corresponding author. Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands. Tel.: +31 10 463 3991; fax: +31 10 463 4420. E-mail address: [email protected] (M. Rivero-Ayerza). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.08.048
into the right atrium through a markedly dilated CS (Fig. 1). It was certain that a conventional left ventricular (LV) lead placement, with a venogram using an occlusive balloon would be virtually impossible. After identification of two potentially adequate CS side branches in the CT images, a right-sided biventricular ICD implantation was planned with magnetic navigation. A 9 F sheath was introduced (ELA Situs LV, ELA Medical, Le Plessis-Robinson Cedex, France) through the right subclavian vein into the right atrium. An intra-cardiac echocardiogram probe (View Mate® EP MedSystems, West Berlin, NJ, USA) was introduced in order to identify the CS os and ensure optimal resynchronization during biventricular pacing. Considering the anatomic characteristics of this particular patient our judgement was that the chances of LV lead displacement when removing the CS were high. For this reason the sheath was positioned in the mid right atrium. A magnetically enabled guide-wire (Cronus Floppy Endovascular Guide wire, Stereotaxis) was introduced and remotely guided up to the CS os. Vectors were oriented in order to follow the same direction of the vessel until reaching the level of the LV lateral wall. At this point, vectors to cannulate the lateral side branch were selected (Fig. 2) and a lateral CS side branch was easily engaged. Afterwards, an over the wire LV pacing lead (ELA Situs OTW) was successfully introduced and advanced distally within the vessel.
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M. Rivero-Ayerza et al. / International Journal of Cardiology 116 (2007) e15–e17
Fig. 1. CT scan seen from a left anterior oblique projection. Note how the LSVC drains into a markedly dilated CS.
Left ventricular pacing threshold was 0.5 V and the LV lead electrogram 15 mV. Using the intra-cardiac echocardiogram adequate resynchronization of ventricular contraction was documented during biventricular pacing. Duration of the QRS was reduced from 172 ms during baseline to 142 ms. 3. Discussion Cardiac resynchronization therapy device implantation is now a common practice for any implanting physician. How-
ever, due to unforeseen reasons, subsequent surgical LV lead positioning is required in up to 10% of the patients [2]. Persistent left superior vena cava is an unusual anatomic variant occurring in approximately 0.5% of patients with normal hearts in the general population and can make pacemaker lead implantation challenging [3,4]. A recent case report and more recently a case series of four patients describe the placement of a CS pacing lead through a left subclavian approach in patients with persistent LSVC requiring resynchronization therapy [4,5]. To the best of our knowledge this is the first report to describe the usefulness of a magnetically guided, right-sided approach, for implantation of a left ventricular pacing lead in a patient with persistent LSVC. During conventional CRT device implantation, a guiding sheath is introduced within the CS and a balloon is inflated to occlude it and obtain an angiogram that allows selection of the ideal LV site available for deploying the pacing lead. However, in the present case the chances of being able to occlude the CS were slim. With the help of a magnetically steered guide-wire, a CT scan and images obtained with an intra-cardiac echocardiogram we were able to perform the implantation without the need of an occlusive CS angiogram. In this way surgical LV lead implantation was avoided. The use of a magnetic navigation system has proven to be a helpful tool for CRT device implantations [1]. Two external magnets (Niobe, Stereotaxis) are positioned at each side of the table in order to generate a magnetic field within the patient. The operator working remotely specifies the orientation of the magnetic field and a single magnet inserted in the tip of a guide-wire (Cronus Floppy Endovascular Guide wire, Stereotaxis) aligns itself with the direction of the
Fig. 2. Orientation of the magnetic vector (green arrow) chosen to engage the lateral CS side branch in a left anterior oblique projection (right panel) and right anterior oblique projection (left panel). Note how the vector and LV lead orientation coincide with that of the virtual lateral side branch of the script (top right corner of each panel). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
M. Rivero-Ayerza et al. / International Journal of Cardiology 116 (2007) e15–e17
magnetic field. This allowed us to both cannulate the CS with the guide-wire in the absence of a sheath and to engage an “ideal” CS side branch that we knew was present from the CT scan. The added value of performing the procedure using an intra-cardiac echocardiogram was double. It first helped us locate the CS os, while remotely manipulating the magnets, in this way allowing us to orient the guide-wire towards it. Secondly, it allowed us to assess whether the chosen pacing site was effectively resynchronizing the ventricles. Incorporating real time images and being able to orient the magnets according to these images will certainly increase success rates in those difficult cases that would otherwise need a surgical approach. References [1] Rivero-Ayerza M, Thornton AS, Theuns DAMJ, et al. Left ventricular lead placement within a coronary sinus side branch using remote magnetic navigation of a guidewire: a feasibility study. J Cardiovasc Electrophysiol 2006;17:128–33.
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[2] DeRose JJ, Ashton RC, Belsley S, et al. Robotically assisted left ventricular epicardial lead implantation for biventricular pacing. J Am Coll Cardiol 2003;41:1414–9. [3] Biffi M, Boriani G, Frabetti L, Bronzetti G, Branzi A. Left superior vena cava persistence in patients undergoing pacemaker or cardioverter defibrillator implantation: a 10 year experience. Chest 2001;120: 139–44. [4] Meijboom WB, Vanderheyden M. Biventricular pacing and persistent left superior vena cava. Case report and review of the literature. Acta Cardiol 2002;57:287–90. [5] Gasparini M, Mantica M, Galimverti P, et al. Biventricular pacing via a persistent left superior vena cava: report of four cases. PACE 2003;26 (Pt II):192–6.
Letter to the Editor
Left ventricular lead implantation assisted by magnetic navigation in a patient with a persistent left superior vena cava Máximo Rivero-Ayerza ⁎, Yves van Belle, Joris Mekel, Luc J. Jordaens Erasmus MC, Rotterdam, The Netherlands Received 25 July 2006; accepted 4 August 2006 Available online 13 November 2006
Abstract In a woman with a persistent left superior vena cava and a dilated coronary sinus, a right-sided biventricular ICD implantation was performed assisted by remote magnetic navigation. Intra-cardiac echocardiography was helpful in locating the coronary sinus os. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiac resynchronization therapy; Persistent left superior vena cava; Magnetic navigation; Heart failure
1. Introduction A magnetic navigation system has been designed with the purpose of allowing remote steering of dedicated guidewires. In this way it becomes possible to reach areas or access vessels that would otherwise be difficult to get to by conventional means. This system has proven to be useful in assisting conventional CRT device implantations [1]. We present the case of a patient with a dilated cardiomyopathy and a persistent left superior vena cava (LSVC). Magnetic navigation (Niobe™ Stereotaxis, St. Louis, MO, USA) allowed successful implantation of a LV pacing lead within a lateral coronary sinus (CS) side branch. 2. Case presentation A 37 year-old female with a Turner syndrome and standard indications for cardiac resynchronization therapy (CRT) was scheduled for implantation of a biventricular ICD device. A CT scan showed a persistent LSVC communicating
⁎ Corresponding author. Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands. Tel.: +31 10 463 3991; fax: +31 10 463 4420. E-mail address: [email protected] (M. Rivero-Ayerza). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.08.048
into the right atrium through a markedly dilated CS (Fig. 1). It was certain that a conventional left ventricular (LV) lead placement, with a venogram using an occlusive balloon would be virtually impossible. After identification of two potentially adequate CS side branches in the CT images, a right-sided biventricular ICD implantation was planned with magnetic navigation. A 9 F sheath was introduced (ELA Situs LV, ELA Medical, Le Plessis-Robinson Cedex, France) through the right subclavian vein into the right atrium. An intra-cardiac echocardiogram probe (View Mate® EP MedSystems, West Berlin, NJ, USA) was introduced in order to identify the CS os and ensure optimal resynchronization during biventricular pacing. Considering the anatomic characteristics of this particular patient our judgement was that the chances of LV lead displacement when removing the CS were high. For this reason the sheath was positioned in the mid right atrium. A magnetically enabled guide-wire (Cronus Floppy Endovascular Guide wire, Stereotaxis) was introduced and remotely guided up to the CS os. Vectors were oriented in order to follow the same direction of the vessel until reaching the level of the LV lateral wall. At this point, vectors to cannulate the lateral side branch were selected (Fig. 2) and a lateral CS side branch was easily engaged. Afterwards, an over the wire LV pacing lead (ELA Situs OTW) was successfully introduced and advanced distally within the vessel.
e16
M. Rivero-Ayerza et al. / International Journal of Cardiology 116 (2007) e15–e17
Fig. 1. CT scan seen from a left anterior oblique projection. Note how the LSVC drains into a markedly dilated CS.
Left ventricular pacing threshold was 0.5 V and the LV lead electrogram 15 mV. Using the intra-cardiac echocardiogram adequate resynchronization of ventricular contraction was documented during biventricular pacing. Duration of the QRS was reduced from 172 ms during baseline to 142 ms. 3. Discussion Cardiac resynchronization therapy device implantation is now a common practice for any implanting physician. How-
ever, due to unforeseen reasons, subsequent surgical LV lead positioning is required in up to 10% of the patients [2]. Persistent left superior vena cava is an unusual anatomic variant occurring in approximately 0.5% of patients with normal hearts in the general population and can make pacemaker lead implantation challenging [3,4]. A recent case report and more recently a case series of four patients describe the placement of a CS pacing lead through a left subclavian approach in patients with persistent LSVC requiring resynchronization therapy [4,5]. To the best of our knowledge this is the first report to describe the usefulness of a magnetically guided, right-sided approach, for implantation of a left ventricular pacing lead in a patient with persistent LSVC. During conventional CRT device implantation, a guiding sheath is introduced within the CS and a balloon is inflated to occlude it and obtain an angiogram that allows selection of the ideal LV site available for deploying the pacing lead. However, in the present case the chances of being able to occlude the CS were slim. With the help of a magnetically steered guide-wire, a CT scan and images obtained with an intra-cardiac echocardiogram we were able to perform the implantation without the need of an occlusive CS angiogram. In this way surgical LV lead implantation was avoided. The use of a magnetic navigation system has proven to be a helpful tool for CRT device implantations [1]. Two external magnets (Niobe, Stereotaxis) are positioned at each side of the table in order to generate a magnetic field within the patient. The operator working remotely specifies the orientation of the magnetic field and a single magnet inserted in the tip of a guide-wire (Cronus Floppy Endovascular Guide wire, Stereotaxis) aligns itself with the direction of the
Fig. 2. Orientation of the magnetic vector (green arrow) chosen to engage the lateral CS side branch in a left anterior oblique projection (right panel) and right anterior oblique projection (left panel). Note how the vector and LV lead orientation coincide with that of the virtual lateral side branch of the script (top right corner of each panel). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
M. Rivero-Ayerza et al. / International Journal of Cardiology 116 (2007) e15–e17
magnetic field. This allowed us to both cannulate the CS with the guide-wire in the absence of a sheath and to engage an “ideal” CS side branch that we knew was present from the CT scan. The added value of performing the procedure using an intra-cardiac echocardiogram was double. It first helped us locate the CS os, while remotely manipulating the magnets, in this way allowing us to orient the guide-wire towards it. Secondly, it allowed us to assess whether the chosen pacing site was effectively resynchronizing the ventricles. Incorporating real time images and being able to orient the magnets according to these images will certainly increase success rates in those difficult cases that would otherwise need a surgical approach. References [1] Rivero-Ayerza M, Thornton AS, Theuns DAMJ, et al. Left ventricular lead placement within a coronary sinus side branch using remote magnetic navigation of a guidewire: a feasibility study. J Cardiovasc Electrophysiol 2006;17:128–33.
e17
[2] DeRose JJ, Ashton RC, Belsley S, et al. Robotically assisted left ventricular epicardial lead implantation for biventricular pacing. J Am Coll Cardiol 2003;41:1414–9. [3] Biffi M, Boriani G, Frabetti L, Bronzetti G, Branzi A. Left superior vena cava persistence in patients undergoing pacemaker or cardioverter defibrillator implantation: a 10 year experience. Chest 2001;120: 139–44. [4] Meijboom WB, Vanderheyden M. Biventricular pacing and persistent left superior vena cava. Case report and review of the literature. Acta Cardiol 2002;57:287–90. [5] Gasparini M, Mantica M, Galimverti P, et al. Biventricular pacing via a persistent left superior vena cava: report of four cases. PACE 2003;26 (Pt II):192–6.