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Ann Thorac Surg 1999;67:958
© 1999 The Society of Thoracic Surgeons

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Commentary

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Invited commentary

Unconventional approaches associated with treating pacemaker and implantable cardiac defibrillator implants are becoming more prevalent because of the increased incidence of device-related complications. This is especially true for younger patients with or without congenital heart disease. Complications range from life-threatening infections, forcing removal and reimplantation of devices, to an inability to insert transvenous pacing leads using conventional procedures. The latter is the subject of the present study.

The techniques presented are improvisations of routine coronary sinus and transatrial implant procedures. The insertion of leads through a transatrial approach is essential in my practice. My recent experiences in more than 100 cases have been both successful and uneventful. It is used in situations where the superior veins cannot or should not be used. The only contraindications are the presence of an infected right medial chest wall and endocarditis. Endocarditis is a contraindication to intravascular pacing.

The electrode is placed in the coronary sinus to pace the left atrium. The electrode must be passed through the coronary sinus into a cardiac vein on the epicardial surface to pace the left ventricle. Left ventricular pacing is used for rate control (as in this article) and is being studied as a technique to improve cardiac function by pacing both the left and right ventricles in patients with congestive heart failure who have a dilated left ventricle. Defibrillator leads occasionally are placed in and through the coronary sinus for cardioversion. At high voltages you can pace both the right atrium and ventricle proximally and the left atrium and ventricle distally. Pacing both the atrium and ventricle is to be avoided because of the loss of a physiologic atrioventricular interval, causing pacemaker syndrome. Once a lead is passed through the coronary sinus into the great cardiac vein or beyond into a tributary cardiac vein, the left ventricle can be paced at low voltages.

I agree that the left-sided approach is usually easier, but it should not discourage other approaches. With proper fluoroscopic techniques, the coronary sinus can be reached from a left or right superior vein or by a transatrial approach. I cannot give precise stylet curvatures for all approaches and heart configurations. However, with practice and proper visualization, the curvature of the stylet can be modified to probe the posterior medial aspect of the right atrium until the lead tip drops into the coronary sinus. The left anterior oblique view allows optimal visualization. Once the lead enters the coronary sinus, its posterior, lateral, and superior course is definitive for a coronary sinus implant, as is the signature of the electrogram obtained from the lead.

An electrode implanted in a vein, such as the coronary sinus or cardiac vein, must be bound to the vein wall or secured by an active fixation device, as used by the authors, to ensure stability. The use of an active fixation device is inherently dangerous unless the pericardial space is obliterated. The Medtronic Model 2118 (Medtronic, Inc, Minneapolis, MN) is the only commercial lead I have used successfully. Conventional leads must be modified for an off-label use in order to bind in a vein.

The excellent results presented in this article are not exceptions but are to be expected using these techniques. If the work of cardiac surgeons in arrhythmia procedures is to warrant the respect it deserves, we must not only become proficient in arrhythmia-related procedures, but also obtain a working knowledge of the language and theory associated with this field of medicine to effectively communicate our results.

Related Article

Unconventional approaches to cardiac pacing in patients with inaccessible cardiac chambers

Daniel J. Goldstein, David Rabkin, and Henry M. Spotnitz
Ann. Thorac. Surg. 1999 67: 952-958. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Charles L. Byrd Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Byrd, C. L. Search for Related Content PubMed Articles by Byrd, C. L. Related Collections Related Article