Pacemaker? Leads?

Kind of a summary of my recent Cath Lab event with my EP and his assistants;

Indications:  Left ventricular dyssynchrony

Conclusion: Unsuccessful attempt of LV lead implant or His bundle pacing from the right subclavian vein. Consider epicardial LV lead placement.

 Procedure: "Attempt LV lead implant. Patient was taken to the EP lab. Venogram was performed which demonstrated patent right subclavian vein. Patient was prepped and draped in sterile fashion. Vancomycin was given for indication of pacemaker lead implant. Local anesthetic was administered to the right shoulder. Incision was made inferior clavicle. A subcutaneous pocket was created with bovie. It was then irrigated with antibiotic solution and inspected for hemostasis. Using modified Seldinger technique, subclavian vein was accessed. Quadrapolar catheter was advanced into the right atrium through a CS sheath. Coronary sinus was accessed with difficulty due to right side approach. CS sheath was advanced into the coronary sinus and the catheter was withdrawn. CS sheath was advanced with difficulty due to orientation of the sheath against the wall of the middle coronary sinus. Sheath was flushed. Venogram was performed. Which showed no lateral branch in the coronary sinus. There was an inferiorly directed middle cardiac vein at the ostium. Despite multiple attempt the middle cardiac vein cannot be engaged due to its inferior direction. CS sheath was removed. A His bundle pacemaker lead delivery sheath was introduced. Due to patient's complete heart block, His bundle pacemaker lead implant was performed empirically and anatomically at several area. Each site demonstrated only RV septum capture without His capture. At this stage, the procedure was aborted due to failure of both LV and His bundle pacemaker lead implant. Total fluoroscopic time 30 minutes."

Anyone able to give me info to increase my undertanding of the above?  I meet with the EP in 10 days,  and I'd like to be better prepared.

THANKS!!!

6 Comments

Comments

by BradyJohn - 2020-03-16 17:04:32

Hi Dave,

There are a few very knowledgeable members on this site.  I'm sure you will get some really helpful feedback.  For the time being, you could copy that report into a word or Google document, double space it and go over it slowly, looking up each term that you don't know.  The basic picture is that they tried two approaches from the right side of your heart and were not successful, so they stopped and now are considering 'epicardial LV lead placement'.  If you start with learning a bit about the epicardium I think you will get a good sense of what they might suggest to you as the next step.

All the best!

John

Another opinion ?

by Gemita - 2020-03-17 06:28:05

Dave after reading your post and the helpful replies, I wonder whether you might benefit from another opinion, if one hasn't already been sought, before proceeding with invasive surgery.   All depends what your EP suggests of course but I would rather be ready for all eventualities.  I am assuming your consultant is very experienced in dealing with complex cases like yours, but if not, might be worth finding the very best EP for an opinion and another attempt?  Clearly an open chest procedure would carry additional risks if this were your only option.

I hope for the very best

Another option

by Dave H - 2020-03-17 11:35:29

I'm seriously looking at this:  https://onlinelibrary.wiley.com/doi/full/10.1002/clc.23300

 

Sounds encouraging

by Gemita - 2020-03-17 12:31:57

Well you have certainly done your homework and the article seems very current.  I wonder what Crustyg can tell us about the VAT technique ?? 

I see there are several open-chest techniques to implanting the LV pacing lead.  As an alternative to VAT, I rather like the idea of the robotic assisted surgery too.  I have heard a great deal about the benefits of robotic surgery which seems to be gaining popularity with many surgeons.  Not sure how advanced robotics are in this area though ??

Well you have certainly got lots to talk about with your EP now Dave and you will be well prepared 

Another Option

by AgentX86 - 2020-03-17 14:01:49

That alterntive certainly possible but it's not one I'd like to take.  As said here a few times, I'd try an top EP or interventional cardiologist placing the LV lead before I'd let a thoracic surgeon have a go at it.  LV placement is a challenge, in any case, but the best will have a higher success than other EPs.  I'd rather wait for a second opinion from the best at this procedure than go for a chest cracker.  If the best EP can't get it done, you have plan-C.

My vote is a second opinion, with no reservations.

Mayo opinion on VAT

by Dave H - 2020-03-17 15:45:45

https://www.mayoclinic.org/tests-procedures/video-assisted-thoracic-surgery/about/pac-20384922

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