Ann Thorac Surg 2002;74:1254-1256
© 2002 The Society of Thoracic Surgeons
Case report
Transesophageal echocardiography guided placement of a coronary sinus pacing lead
John H. Artrip, MDa,
Darren Sukerman, BSa,
Marc L. Dickstein, MDb,
Henry M. Spotnitz, MD*a
a Department of Surgery, Division of Cardiothoracic Surgery, Columbia University, New York, New York, USA
b Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
Accepted for publication April 30, 2002.
* Address reprint requests to Dr Spotnitz, Department of Surgery, Division of Cardiothoracic Surgery, College of Physicians and Surgeons, Columbia University MHB 7-435, 177 Fort Washington Ave, New York, NY 10032 USA
e-mail: hms2{at}columbia.edu
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Abstract
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Cardiac resynchronization therapy for the treatment of medically refractory heart failure requires coronary sinus lead placement for left ventricular pacing. Coronary sinus lead placement is technically difficult with success rates reported between 53% to 98% and implantation times ranging from 90 minutes to 5 hours. We report the use of intraoperative transesophageal echocardiography to guide coronary sinus lead placement when conventional fluoroscopy failed. Transesophageal echocardiography may improve the success rate with coronary sinus lead placement and decrease the operative time required. This should be used with caution, however, as sedation, possible intubation, and esophageal manipulation have potentially morbid consequences in patients with advanced congestive heart failure.
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Introduction
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Permanent ventricular pacing was initiated clinically with epicardial leads sewn to the left ventricle by thoracotomy. More recently, transvenous lead insertion into the right ventricle has become the clinical standard. Epicardial pacing is presently reserved for venous or tricuspid valve obstruction, congenital malformations with intracardiac shunts, or medical conditions with high right ventricular pacing thresholds (endocardial fibroelastosis, cardiac amyloidosis) [1]. Left ventricular pacing is reemerging as a treatment option for patients with severe heart failure (CHF) and intraventricular conduction disturbances [2]. In CHF, intraventricular conduction disturbance is believed to lessen the rate of ventricular pressure generation (peak dP/dt) and increase the time interval for mitral regurgitation [3]. Biventricular pacing has been shown to favorably affect objective and subjective measures of CHF in clinical trials [2].
Left ventricular pacing is an essential part of the biventricular strategy. Epicardial insertion of left ventricular leads has often been accompanied by high mortality in patients with CHF [4]. Left ventricular pacing through coronary sinus (CS) lead insertion is currently preferred, but this can be technically challenging. We report CS lead insertion with intraoperative transesophageal echocardiography (TEE) guidance in a situation where conventional fluoroscopic guidance failed.
An 83-year-old man with ischemic cardiomyopathy was admitted to the coronary care unit with dyspnea at rest and CHF (New York Association functional class IV). During therapy with intravenous dobutamine and lasix, intermittent second- and third-degree atrioventricular block were noted. Despite maximal medical therapy, his condition deteriorated with progressive renal insufficiency and respiratory failure requiring intubation. He was referred for DDD biventricular pacing. His family understood that his prognosis was poor but requested all available effort to reverse his downhill course.
Intraoperatively, the os to the CS could not be located despite extensive efforts. Transesophageal echocardiography was then instituted and quickly demonstrated the location of the CS in relation to the pacemaker lead. The lead (Medtronic model 4024-85) was then inserted with minimal difficulty (Fig 1).
Left ventricular pacing threshold was 2.5 V. Right atrial and ventricular leads were then placed with fluoroscopic guidance. After pacemaker implantation (Medtronic kdr702 [Medtronic Inc, Minneapolis, MN]) the patient’s hemodynamics improved, with increased systolic blood pressure and decreased wedge pressures. Cardiac output nearly doubled, from 2.7 to 5.0 L/min. The patient was returned to the coronary care unit in stable condition. Despite the favorable response he developed sepsis related to his prolonged intensive care unit course and died.
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Fig 1. Anterior-posterior chest roentgenogram taken after the placement of the coronary sinus pacing lead. Note the position of the coronary sinus lead transversing the atrioventricular groove. This is somewhat atypical in that the coronary sinus lead is cephalad to the right ventricular lead at the tricuspid annulus.
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Comment
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Cardiac resynchronization for the treatment of medically refractory CHF in selected patients is likely to expand the indications for left ventricular pacing [2]. However, CS lead placement is technically difficult. It requires locating the os of the CS in the right atrium, defining CS anatomy, and positioning the lead in a stable location with acceptable left ventricular pacing thresholds and adequate sensing. The CS courses within the atrioventricular groove in close proximity to both the atria and ventricles. Left ventricular pacing is best achieved from a location within lateral or posterior branches of the CS that overlie the left ventricle. Current clinical trials use special cannulas as well as leads designed to pass over fine guidewires into branches of the CS. Guiding catheters and CS leads from the MIRACLE trial are available in the United States and were used in the patient described, although the lead finally inserted in the CS was a standard model.
With posteroanterior fluoroscopy, the Os is generally located in the extreme caudad of the left lateral aspect of the right atrium, but there is considerable variation in this anatomy [5]. With balloon-tipped catheters and venous contrast agents the CS is successfully located 53% to 98% of the time [2], and in the multicenter in sync randomized clinical evaluation (MIRACLE) trial the implantation success rate was 93%. Implant time in our local experience has varied from 90 minutes to 5 hours, similar to other clinical reports. In the case presented here, with prior experience in more than 20 patients, we were unable to cannulate the CS within 3 hours, despite the assistance of fluoroscopy, special leads, and cannulas. It appeared unlikely that CS entry was possible in this patient using the standard methods available to us. We had previously used intraoperative echocardiography to guide catheters across the aortic valve, and other investigators have used TEE to guide the positioning of CS cannulas [6], but TEE had not been used to aid pacemaker insertion. As this patient was already intubated and sedated, TEE was easily instituted without additional anesthesia. The TEE probe enabled accurate localization of the CS Os with respect to the pacing lead, which was not possible with fluoroscopy alone.
Unlike fluoroscopy, echocardiography visualizes the CS without contrast agents. In adult cardiac surgery TEE is routinely used to confirm CS cannulation of the retrograde cardioplegia catheter (Fig 2);
however, this is invasive and requires sedation. The clinical condition of this patient facilitated TEE, but additional sedation and operating time might not be justified in other circumstances.
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Fig 2. Transesophageal echocardiography view of the coronary sinus (CS). This transesophageal image is obtained by slight retroflexion of the probe tip situated in the mid to distal esophagus, which is set on the horizontal plane (0 degrees). The coronary sinus is easily visualized by the echolucent structure in the atrioventricular groove that is seen opening into the right atrium (RA) just above the tricuspid valve. (RV = right ventricle.)
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If clinical trials continue to be favorable, biventricular pacing may be recommended for patients with advanced CHF and QRS duration more than 120 milliseconds, roughly 10% to 20% of the total heart failure population. Transesophageal echocardiography is one of many adjuncts that are likely to facilitate CS lead cannulation. Others include biplane fluoroscopy with or without contrast injection, steerable guidewires with motion controllable in three planes, intracardiac echocardiography, and over the wire lead designs. Epicardial lead insertion could also have a renewed role in this setting, but minimal access techniques are likely to be preferred in patients with advanced CHF.
We describe TEE guidance for placement of CS pacing leads as a feasible strategy in difficult implants. If implantation of biventricular pacemakers becomes common, selective use of TEE is likely to improve the overall success rate with CS lead placement and could decrease the operative time required. This methodology should be used with caution, however, as sedation, possible intubation, and esophageal manipulation have potentially morbid consequences in patients with advanced CHF.
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References
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- Goldstein D.J., Rabkin D., Spotnitz H.M. Unconventional approaches to cardiac pacing in patients with inaccessible cardiac chambers. Ann Thorac Surg 1999;76:952-958.
- Cazeau S., Leclercq C., Lavergne T., et al. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction. N Engl J Med 2001;344:873-880.[Abstract/Free Full Text]
- Xiao H.B., Brecker J.D., Gibson D.G. Effects of abnormal activation on the time course of the left ventricular pressure pulse in dilated cardiomyopathy. Br Heart J 1992;68:403-407.[Abstract/Free Full Text]
- Saxon L.A., Boehmer J.P., Hummel J., et al. Biventricular pacing in patients with congestive heart failure: two prospective randomized trials. Am J Cardiol 1999;83:120D-123D.[Medline]
- Meisel E., Pfeiffer D., Engelmann L., et al. Investigation of coronary venous anatomy by retrograde venography in patients with malignant ventricular tachycardia. Circulation 2001;104:442-447.[Abstract/Free Full Text]
- Plotkin I.M., Collard C.D., Aranki S.F., et al. Percutaneous coronary sinus cannulation guided by transesophageal echocardiography. Ann Thorac Surg 1998;66:2085-2087.[Abstract/Free Full Text]
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Abstract
Introduction
