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Usefulness of temporary left ventricular pacing through the coronary sinus as an adjunct to transfemoral percutaneous coronary intervention
Usefulness of Temporary Left Ventricular Pacing Through the Coronary Sinus as an Adjunct to Transfemoral Percutaneous Coronary Intervention Patrick H. McNulty, MD, Keith S. Rice, MD, Rakesh B. Saraiya, MD, Jennifer McCann, BA, Steven M. Ettinger, MD, Ian C. Gilchrist, MD, Mark Kozak, and Charles E. Chambers, MD In 10 patients who underwent percutaneous coronary intervention involving the right coronary artery, a new procedure for adjunctive temporary transfemoral pacing of the left ventricle through the coronary sinus was tested. The procedure was successful in 8 of 10 patients and could be performed in <5 minutes by experienced operators and supervised cardiology fellows. 䊚2004 by Excerpta Medica, Inc. (Am J Cardiol 2004;94:1055–1057)
or percutaneous coronary intervention (PCI) performed through the femoral artery, cardiac pacing F when acutely indicated is usually accomplished by passing a 5Fr or 6Fr wire from the adjacent femoral vein into the right ventricle. Transvenous right ventricular endocardial pacing can usually be performed quickly and is successful in ⬎95% of all patients.1 Nevertheless, in some patients who require emergency cardiac pacing during right coronary artery PCI, the right ventricular endocardium may be refractory to electrical capture because of ischemia or infarction, whereas in others, anatomic factors may make right ventricular pacing difficult or unappealing. For such patients, a technique for the temporary transfemoral pacing of the left ventricle would be a useful alternative if it could be performed quickly using materials readily available in most catheterization laboratories. In this report, we describe our initial experience with such a technique. •••
Adult subjects (n ⫽ 10) who underwent elective PCI (all balloon angioplasty with stenting) involving lesions in the proximal segment of dominant right coronary arteries were enrolled in a feasibility study of prophylactic transfemoral venous left ventricular pacing through the coronary sinus. The study was approved by the Penn State College of Medicine institutional review board, and all subjects gave written informed consent. All subjects were in normal sinus rhythm. Subjects’ characteristics are listed in Table 1. Procedures 1 through 5 were performed by an operator with previous experience in transfemoral coronary sinus catheterization, and procedures 6 through 10 were performed by a cardiology fellow who had From the Division of Cardiology, Penn State College of Medicine, Hershey, Pennsylvania. Dr. McNulty’s address is: Division of Cardiology/H047, Penn State College of Medicine, 500 University Drive, Hershey, Pennsylvania 17033. E-mail: [email protected]. Manuscript received April 30, 2004; revised manuscript received and accepted June 25, 2004. ©2004 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 94 October 15, 2004
MD,
observed the first 5 procedures and was directly supervised by the experienced operator. A 5Fr plastic sheath was placed into the right (n ⫽ 9) or left (n ⫽ 1) femoral vein and used to introduce a 5Fr Simmons-2 side-hole catheter (Cook Medical, Chicago, Illinois) into the mid-coronary sinus, as previously reported by Winters et al2 and ourselves.3–5 Through this catheter, a limited coronary sinus angiogram was performed in the anteroposterior projection to delineate the anatomy of its left ventricular venous branches (Figure 1). A conventional stainless steel angioplasty guidewire (Direct wire, Medtronic, Inc., Minneapolis, Minnesota; diameter 0.014 in, length 175 cm) was then introduced into the coronary sinus and advanced until its tip entered a lateral left ventricular vein. The extracorporeal end of this wire was connected by a sterile alligator clip to the distal (negative) pole of a standard external pulse generator whose proximal (positive) pole was connected by a second alligator clip to a standard radiolucent transcutaneous pacing lead (ZOLL Medical Corporation, Chelmsford, Massachusetts) affixed to the skin of the left lateral chest wall. This system is illustrated in Figure 2. The time elapsed from inserting the Simmons-2 catheter into the femoral introducer sheath until the achievement of a stable pacing wire position in a coronary vein was recorded. The pulse generator’s pacing rate was then set less than each subject’s intrinsic heart rate, and the ability of the 0.014-in wire to sense intrinsic cardiac electrical activity was noted. The generator’s pacing rate was then set at 20 beats/ min greater than the intrinsic heart rate and its electrical output increased gradually until left ventricular capture (confirmed by the appearance of a left ventricular electrogram on the surface electrocardiogram) was observed. This electrical capture threshold was also recorded. All data are given as means ⫾ SDs. After the completion of pacer insertion and testing, heparin and a glycoprotein IIb/IIIa antagonist were administered, and coronary angiography and PCI were performed in standard fashion. Patient results are listed in Table 1. Left ventricular pacing through the femoral vein and coronary sinus was successful in 8 of the 10 subjects. In 1 subject, the coronary sinus could not be cannulated with the Simmons-2 catheter, and the procedure was abandoned after 15 minutes; in a second patient, the heart could not be electrically captured at maximum generator output (20 mA) despite an anatomically appropriate position of the coronary vein pacing wire. In the 8 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2004.06.067
1055
TABLE 1 Study Subject Characteristics and Procedural Variables Subject
Age (yrs)/Sex
Operator
Procedure Time (mins)
Capture Threshold (mA)
Electrical Sensing
1 2 3 4 5 6 7 8 9 10
53F 67F 76F 49M 81F 52M 48M 75F 65M 51M
E E E E E T T T T T
2.8 2.6 4.7 3.9 2.6 7.0 3.6 Failed 4.2 3.9
20 15 5 Failed 20 7 7 N/A 20 7
0 ⫹ ⫹ 0 ⫹ ⫹ 0 0 ⫹
Demographic characteristics and procedural variables of subjects who underwent temporary transfemoral left ventricular pacing. Procedures are listed in chronologic order. E ⫽ experienced operator; T ⫽ supervised cardiology trainee.
subjects in whom the procedure was fully successful, the time elapsed from the insertion of the Simmons-2 catheter into the femoral venous sheath to the attainment of a stable coronary vein wire position averaged 3.8 ⫾ 1.4 minutes (range 1.5 to 7.0), and electrical capture threshold averaged 13 ⫾ 6 mA. Procedure times were only slightly longer (4.6 ⫾ 1.6 vs 3.3 ⫾ 1.0 minutes, p ⫽ 0.19) for the 5 procedures performed by supervised trainees than for the 5 performed by the experienced operator. No complications were noted, and in 2 subjects, the coronary vein wire was observed to spontaneously pace the heart in response to bradycardia or asystole during the subsequent right coronary artery PCI. •••
FIGURE 1. (A) Fluoroscopic image in the anteroposterior projection showing a Simmons-2 catheter inserted into the distal coronary sinus from the right femoral vein. A 0.014-in angioplasty guidewire was introduced through the Simmons catheter into a lateral left ventricular vein. Note that the wire tip was formed into a nontraumatic J configuration. (B) Coronary sinus (CS) angiogram performed through the Simmons catheter, showing the anatomy of the CS and its venous branches.
1056 THE AMERICAN JOURNAL OF CARDIOLOGY姞
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The conventional alternative to right ventricular pacing in patients who develop bradycardia or asystole during PCI has been to pace the left ventricle using an intracoronary guidewire.6,7 Although effective, this technique usually requires the interruption or abandonment of the PCI procedure. In contrast, the technique we describe can be performed in conjunction with transfemoral PCI without interrupting the interventional procedure. The present study suggests that transfemoral left ventricular pacing through the coronary sinus can be performed quickly and safely in most patients who undergo PCI, using simple equipment and materials. The observation that cardiology fellows supervised by an experienced operator could perform transfemoral venous left ventricular pacer insertion almost as quickly as the experienced operator himself could suggests that this procedure is also relatively easy to teach and to learn. Several technical points deserve comment. The procedure we describe depends on the unique suitability of the Simmons catheter shape for cannulating the coronary sinus through the femoral route. We have found the Simmons-2 size most suitable for patients with normalsized right atria,3–5 but the larger Simmons-3 catheter may be more useful in patients with large hearts.8 To minimize the potential for coronary vein trauma, we used a relatively floppy 0.014-in guidewire and
OCTOBER 15, 2004
our subjects, electrical capture could be obtained only at the maximum electrical output of the temporary pacing generator (20 mA), and in 1 subject, electrical capture was not successful at 20 mA despite an apparently adequate wire position. Because our primary intention was to test an emergency technique for left ventricular pacing that could be performed quickly using simple materials, the system we describe naturally contains inefficient electrical elements. It seems likely that simple refinements (e.g., replacing alligator clips with insulated electrical contacts, insulating the shaft of the stainless steel guidewire) might considerably reduce the energy requirement for left ventricular electrical capture. A final point is that all procedures in this report were performed or supervised by an operator with previous experience using the Simmons catheter for transfemoral coronary sinus cannulation. Acknowledgment: We thank the staff of the Penn State Cardiovascular Center for assistance in the performance of these studies.
1. Hynes JK, Holmes DR, Harrison CE. Five-year experience with temporary
FIGURE 2. Schematic showing configuration used for transfemoral left ventricular pacing through the coronary sinus. Electrical current is delivered from a standard temporary pacing generator to a bipolar system in which a cutaneous electrode (ZOLL Medical Corporation) affixed to the left lateral chest wall serves as the proximal (positive) pole and a 0.014-in stainless steel guidewire positioned in a coronary vein serves as the distal (negative) pole.
endeavored to create a J bend at the wire tip before advancing it out of the coronary sinus into small venous branches. Regarding the electrical performance of the system we describe, its average capture threshold (13 mA) was greater than that usually observed for 5Fr or 6Fr temporary pacing wires in good contact with the right ventricular endocardium. In 3 of
pacemaker therapy in the coronary care unit. Mayo Clin Proc 1983;58:122–126. 2. Winters KJ, Lasala JM, Eisenberg PR, Smith SC, Sewall DJ, Shelton ME.
Modified heparin-bonded catheter for cannulation of the coronary sinus from the femoral vein. Cathet Cardiovasc Diagn 1996;39:433– 437. 3. McNulty PH. Comparison of local and systemic effects of insulin on myocardial glucose extraction in ischemic heart disease. Am J Physiol 2000;278:H741– H747. 4. McNulty PH, Jacob R, Deckelbaum LI, Young LH. Effect of hyperinsulinemia on myocardial amino acid uptake in patients with coronary artery disease. Metabolism 2000;49:1365–1369. 5. Jagasia D, Whiting JM, Concato J, Pfau S, McNulty PH. Effect of non-insulindependent diabetes mellitus on myocardial insulin responsiveness in patients with ischemic heart disease. Circulation 2001;103:1734 –1739. 6. Laird JR, Hull R, Stajduhar KC, Weston LT, Kufs W, Wortham DC. Transcoronary cardiac pacing during myocardial ischemia. Cathet Cardiovasc Diagn 1993;30:162–165. 7. Meier B, Rutishauser W. Coronary pacing during percutaneous transluminal coronary angioplasty. Circulation 1985;71:557–561. 8. McNulty PH, Markle T, Silber D, Chambers CE, Boehmer J, McLain D. Coordinate regulation of heart and limb muscle amino acid metabolism in patients with dilated cardiomyopathy (abstr). Circulation 2001;104:3826.
BRIEF REPORTS
1057
or percutaneous coronary intervention (PCI) performed through the femoral artery, cardiac pacing F when acutely indicated is usually accomplished by passing a 5Fr or 6Fr wire from the adjacent femoral vein into the right ventricle. Transvenous right ventricular endocardial pacing can usually be performed quickly and is successful in ⬎95% of all patients.1 Nevertheless, in some patients who require emergency cardiac pacing during right coronary artery PCI, the right ventricular endocardium may be refractory to electrical capture because of ischemia or infarction, whereas in others, anatomic factors may make right ventricular pacing difficult or unappealing. For such patients, a technique for the temporary transfemoral pacing of the left ventricle would be a useful alternative if it could be performed quickly using materials readily available in most catheterization laboratories. In this report, we describe our initial experience with such a technique. •••
Adult subjects (n ⫽ 10) who underwent elective PCI (all balloon angioplasty with stenting) involving lesions in the proximal segment of dominant right coronary arteries were enrolled in a feasibility study of prophylactic transfemoral venous left ventricular pacing through the coronary sinus. The study was approved by the Penn State College of Medicine institutional review board, and all subjects gave written informed consent. All subjects were in normal sinus rhythm. Subjects’ characteristics are listed in Table 1. Procedures 1 through 5 were performed by an operator with previous experience in transfemoral coronary sinus catheterization, and procedures 6 through 10 were performed by a cardiology fellow who had From the Division of Cardiology, Penn State College of Medicine, Hershey, Pennsylvania. Dr. McNulty’s address is: Division of Cardiology/H047, Penn State College of Medicine, 500 University Drive, Hershey, Pennsylvania 17033. E-mail: [email protected]. Manuscript received April 30, 2004; revised manuscript received and accepted June 25, 2004. ©2004 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 94 October 15, 2004
MD,
observed the first 5 procedures and was directly supervised by the experienced operator. A 5Fr plastic sheath was placed into the right (n ⫽ 9) or left (n ⫽ 1) femoral vein and used to introduce a 5Fr Simmons-2 side-hole catheter (Cook Medical, Chicago, Illinois) into the mid-coronary sinus, as previously reported by Winters et al2 and ourselves.3–5 Through this catheter, a limited coronary sinus angiogram was performed in the anteroposterior projection to delineate the anatomy of its left ventricular venous branches (Figure 1). A conventional stainless steel angioplasty guidewire (Direct wire, Medtronic, Inc., Minneapolis, Minnesota; diameter 0.014 in, length 175 cm) was then introduced into the coronary sinus and advanced until its tip entered a lateral left ventricular vein. The extracorporeal end of this wire was connected by a sterile alligator clip to the distal (negative) pole of a standard external pulse generator whose proximal (positive) pole was connected by a second alligator clip to a standard radiolucent transcutaneous pacing lead (ZOLL Medical Corporation, Chelmsford, Massachusetts) affixed to the skin of the left lateral chest wall. This system is illustrated in Figure 2. The time elapsed from inserting the Simmons-2 catheter into the femoral introducer sheath until the achievement of a stable pacing wire position in a coronary vein was recorded. The pulse generator’s pacing rate was then set less than each subject’s intrinsic heart rate, and the ability of the 0.014-in wire to sense intrinsic cardiac electrical activity was noted. The generator’s pacing rate was then set at 20 beats/ min greater than the intrinsic heart rate and its electrical output increased gradually until left ventricular capture (confirmed by the appearance of a left ventricular electrogram on the surface electrocardiogram) was observed. This electrical capture threshold was also recorded. All data are given as means ⫾ SDs. After the completion of pacer insertion and testing, heparin and a glycoprotein IIb/IIIa antagonist were administered, and coronary angiography and PCI were performed in standard fashion. Patient results are listed in Table 1. Left ventricular pacing through the femoral vein and coronary sinus was successful in 8 of the 10 subjects. In 1 subject, the coronary sinus could not be cannulated with the Simmons-2 catheter, and the procedure was abandoned after 15 minutes; in a second patient, the heart could not be electrically captured at maximum generator output (20 mA) despite an anatomically appropriate position of the coronary vein pacing wire. In the 8 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2004.06.067
1055
TABLE 1 Study Subject Characteristics and Procedural Variables Subject
Age (yrs)/Sex
Operator
Procedure Time (mins)
Capture Threshold (mA)
Electrical Sensing
1 2 3 4 5 6 7 8 9 10
53F 67F 76F 49M 81F 52M 48M 75F 65M 51M
E E E E E T T T T T
2.8 2.6 4.7 3.9 2.6 7.0 3.6 Failed 4.2 3.9
20 15 5 Failed 20 7 7 N/A 20 7
0 ⫹ ⫹ 0 ⫹ ⫹ 0 0 ⫹
Demographic characteristics and procedural variables of subjects who underwent temporary transfemoral left ventricular pacing. Procedures are listed in chronologic order. E ⫽ experienced operator; T ⫽ supervised cardiology trainee.
subjects in whom the procedure was fully successful, the time elapsed from the insertion of the Simmons-2 catheter into the femoral venous sheath to the attainment of a stable coronary vein wire position averaged 3.8 ⫾ 1.4 minutes (range 1.5 to 7.0), and electrical capture threshold averaged 13 ⫾ 6 mA. Procedure times were only slightly longer (4.6 ⫾ 1.6 vs 3.3 ⫾ 1.0 minutes, p ⫽ 0.19) for the 5 procedures performed by supervised trainees than for the 5 performed by the experienced operator. No complications were noted, and in 2 subjects, the coronary vein wire was observed to spontaneously pace the heart in response to bradycardia or asystole during the subsequent right coronary artery PCI. •••
FIGURE 1. (A) Fluoroscopic image in the anteroposterior projection showing a Simmons-2 catheter inserted into the distal coronary sinus from the right femoral vein. A 0.014-in angioplasty guidewire was introduced through the Simmons catheter into a lateral left ventricular vein. Note that the wire tip was formed into a nontraumatic J configuration. (B) Coronary sinus (CS) angiogram performed through the Simmons catheter, showing the anatomy of the CS and its venous branches.
1056 THE AMERICAN JOURNAL OF CARDIOLOGY姞
VOL. 94
The conventional alternative to right ventricular pacing in patients who develop bradycardia or asystole during PCI has been to pace the left ventricle using an intracoronary guidewire.6,7 Although effective, this technique usually requires the interruption or abandonment of the PCI procedure. In contrast, the technique we describe can be performed in conjunction with transfemoral PCI without interrupting the interventional procedure. The present study suggests that transfemoral left ventricular pacing through the coronary sinus can be performed quickly and safely in most patients who undergo PCI, using simple equipment and materials. The observation that cardiology fellows supervised by an experienced operator could perform transfemoral venous left ventricular pacer insertion almost as quickly as the experienced operator himself could suggests that this procedure is also relatively easy to teach and to learn. Several technical points deserve comment. The procedure we describe depends on the unique suitability of the Simmons catheter shape for cannulating the coronary sinus through the femoral route. We have found the Simmons-2 size most suitable for patients with normalsized right atria,3–5 but the larger Simmons-3 catheter may be more useful in patients with large hearts.8 To minimize the potential for coronary vein trauma, we used a relatively floppy 0.014-in guidewire and
OCTOBER 15, 2004
our subjects, electrical capture could be obtained only at the maximum electrical output of the temporary pacing generator (20 mA), and in 1 subject, electrical capture was not successful at 20 mA despite an apparently adequate wire position. Because our primary intention was to test an emergency technique for left ventricular pacing that could be performed quickly using simple materials, the system we describe naturally contains inefficient electrical elements. It seems likely that simple refinements (e.g., replacing alligator clips with insulated electrical contacts, insulating the shaft of the stainless steel guidewire) might considerably reduce the energy requirement for left ventricular electrical capture. A final point is that all procedures in this report were performed or supervised by an operator with previous experience using the Simmons catheter for transfemoral coronary sinus cannulation. Acknowledgment: We thank the staff of the Penn State Cardiovascular Center for assistance in the performance of these studies.
1. Hynes JK, Holmes DR, Harrison CE. Five-year experience with temporary
FIGURE 2. Schematic showing configuration used for transfemoral left ventricular pacing through the coronary sinus. Electrical current is delivered from a standard temporary pacing generator to a bipolar system in which a cutaneous electrode (ZOLL Medical Corporation) affixed to the left lateral chest wall serves as the proximal (positive) pole and a 0.014-in stainless steel guidewire positioned in a coronary vein serves as the distal (negative) pole.
endeavored to create a J bend at the wire tip before advancing it out of the coronary sinus into small venous branches. Regarding the electrical performance of the system we describe, its average capture threshold (13 mA) was greater than that usually observed for 5Fr or 6Fr temporary pacing wires in good contact with the right ventricular endocardium. In 3 of
pacemaker therapy in the coronary care unit. Mayo Clin Proc 1983;58:122–126. 2. Winters KJ, Lasala JM, Eisenberg PR, Smith SC, Sewall DJ, Shelton ME.
Modified heparin-bonded catheter for cannulation of the coronary sinus from the femoral vein. Cathet Cardiovasc Diagn 1996;39:433– 437. 3. McNulty PH. Comparison of local and systemic effects of insulin on myocardial glucose extraction in ischemic heart disease. Am J Physiol 2000;278:H741– H747. 4. McNulty PH, Jacob R, Deckelbaum LI, Young LH. Effect of hyperinsulinemia on myocardial amino acid uptake in patients with coronary artery disease. Metabolism 2000;49:1365–1369. 5. Jagasia D, Whiting JM, Concato J, Pfau S, McNulty PH. Effect of non-insulindependent diabetes mellitus on myocardial insulin responsiveness in patients with ischemic heart disease. Circulation 2001;103:1734 –1739. 6. Laird JR, Hull R, Stajduhar KC, Weston LT, Kufs W, Wortham DC. Transcoronary cardiac pacing during myocardial ischemia. Cathet Cardiovasc Diagn 1993;30:162–165. 7. Meier B, Rutishauser W. Coronary pacing during percutaneous transluminal coronary angioplasty. Circulation 1985;71:557–561. 8. McNulty PH, Markle T, Silber D, Chambers CE, Boehmer J, McLain D. Coordinate regulation of heart and limb muscle amino acid metabolism in patients with dilated cardiomyopathy (abstr). Circulation 2001;104:3826.
BRIEF REPORTS
1057