Clinical investigation of left ventricular pacing using coronary sinus in patients with mechanical prosthetic tricuspid valve replacement

Abstract

Background

Although transvenous right ventricular (RV) endocardial lead placement is routine practice in clinical pacing, RV inaccessibility in certain clinical situations mandates the search for other sites.

Hypothesis

This study is aimed to verify whether left ventricular lead through coronary sinus is safe and efficient.

Methods

Based on a retrospective analysis of a single‐center series of 4 patients with inaccessibility for RV pacing, we report on the feasibility and reliability of coronary sinus (CS) pacing via left ventricular (LV) lead, which usually is used in cardiac resynchronization therapy. Four patients with valvular heart disease and bradycardias post–mechanical prosthetic tricuspid valve replacement were studied. The LV leads were implanted into the lateral vein or great cardiac vein of the CS, and all parameters were programmed postprocedure.

Results

In all cases procedures yielded favorable parameters, with 1 CS dissection. At long‐term follow‐up, there was no threshold increase or lead dislocation.

Conclusions

LV lead implantation through the CS appears safe and efficacious in patients with inaccessibility for RV pacing.

1. INTRODUCTION

Clinical pacing routinely involves transvenous right ventricular (RV) endocardial lead placement. However, in certain clinical situations, such as in organic tricuspid valve diseases requiring RV repair or replacement, the RV becomes inaccessible, requiring search for other sites.1, 2 To this end, epicardial pacemaker lead implantation usually is associated with development of high threshold and requires limited thoracotomy.3 Ventricular pacing through the coronary sinus (CS) mainly is used in cardiac resynchronization therapy in patients with heart failure, and its most common complications include diaphragmatic stimulation, CS dissection, lead dislodgement, and high pacing threshold.

2. METHODS/RESULTS

For the 4 cases reported here, satisfactory pacing data were collected during long‐term (≥1 year; mean duration, 2.1 years) follow‐up of ventricular pacing through the CS, suggesting that this technique enables a minimally invasive approach and effective stimulation for patients with a mechanical prosthetic tricuspid valve.

Overall, the 4 patients studied had a mean age of 53.6 ± 7.92 years, were female, had valvular heart disease, and were on warfarin. All values did not differ significantly after left ventricular (LV) lead implantation using the CS and at follow‐up (Table 1). All patients underwent chest x‐ray 2 days after implantation; there were no cases of lead dislodgment.

Table 1.

Sensing, threshold, and impedance values at implantation and follow‐up

	At Implantation	At Follow‐up	P Value
Sensing, mV	9.82 ± 2.23	9.22 ± 1.81	0.36
Threshold, V/0.4 ms	1.32 ± 0.41	1.20 ± 0.21	0.23
Impedance, ohms	598.1 ± 198.2	593.0 ± 52.0	0.13

2.1. Patient 1

A 47‐year‐old woman who had undergone closed mitral commissurotomy for rheumatic heart disease 29 years before was treated with embolectomy in the femoral artery 2 years earlier. Then, tricuspid and mitral valves were replaced with mechanical valves. After her surgery, she experienced palpitation and syncope. Several episodes of atrial fibrillation (AF) were documented during a 24‐h recording, alternating with episodes of long R‐R interval, which made pacemaker implantation necessary. The lateral vein of the CS could not be used because of CS dissection during angiography. Therefore, a bipolar endocardial pacing lead (Medtronic 4194; Medtronic, Minneapolis, MN) was implanted into the great cardiac vein of the CS via the left subclavian vein (Figure 1). The lead was connected to a single‐chamber pacemaker located subpectorally. Measurements at implantation were as follows: R wave of 10.2 mV, ventricular threshold of 0.8 V at 0.4 ms, and impedance of 602 Ω.

Figure 1.

Implantation of LV lead through CS, showing (A) lateral branch of CS (white arrow) and GCV (black arrow), in LAO angiographic view; (B) CS dissection secondary to further angiography, in AP view; and (C) the bipolar pacing lead finally inserted into the GCV. The red and yellow arrows point to the mechanical tricuspid and mitral valves, respectively. The green arrow shows the LV lead in the GCV of the CS. Abbreviations: AP, anteroposterior; GCV, great cardiac vein; CS, coronary sinus; LAO, left anterior oblique; LV, left ventricular

2.2. Patient 2

A 47‐year‐old woman with rheumatic heart disease and AF underwent mitral, tricuspid, and aortic valve replacement with mechanical prosthesis. One year after that operation, she experienced palpitation and syncope. High‐degree atrioventricular (AV) block was documented during a 24‐h recording, which made pacemaker implantation necessary. After accessing the left subclavian vein, a guiding catheter (Medtronic 6250C/S) was introduced and placed in the ostium of the CS, and a bipolar endocardial pacing lead (Medtronic 4195) was implanted under angiography guidance into a lateral branch of the CS (Figure 2). The lead was connected to a single‐chamber pacemaker located subpectorally. Measurements at implantation were as follows: R wave of 12.8 mV, ventricular threshold of 1.2 V at 0.4 ms, and impedance of 480 Ω.

Figure 2.

Implantation of LV lead through coronary sinus (CS), showing (A) the lateral vein of CS (black arrow) and (B) the mechanical tricuspid, mitral, and aortic valves (red, yellow, and white arrows, respectively). The LV lead is in the lateral vein of CS (LAO, green arrow). Abbreviations: CS, coronary sinus; LAO, left anterior oblique; LV, left ventricular

2.3. Patient 3

A 64‐year‐old woman with rheumatic heart disease underwent percutaneous balloon mitral valvuloplasty 10 years ago, and mitral, tricuspid, and aortic valve replacement with mechanical prostheses 4 years ago. She also underwent the Maze operation for AF and 6 months later experienced dizziness. Sinus arrest and high‐degree AV block were documented during a 24‐h recording. A dual‐chamber pacemaker was implanted for sinus arrest and high‐degree AV block.

The display of the anterior‐lateral vein of the CS was not clear during the angiography, but finally the target vein was found with the guiding wire. A bipolar pacing lead (Medtronic 4194) was inserted in the lateral branch of the CS (Figure 3), and an atrial lead (Medtronic 5076) was fixed into the lateral wall of the right atrium. An endocardial ventricular potential of 7.7 mV was detected with a pacing threshold of 1.6 V at 0.4 ms and impedance of 435 Ω.

Figure 3.

Implantation of LV lead through CS. In (A) and (B) the black arrow shows the anterior‐lateral vein of CS demonstrated by angiography and guiding wire. (C) The pacing lead was inserted into the target vein. (D) The red and yellow arrows show the mechanical tricuspid and mitral valves, respectively. The green arrow shows that the LV lead is in the anterior‐lateral vein of CS. The patient had sinus rhythm and received DDD pacemaker implantation. Abbreviations: CS, coronary sinus; DDD, dual pacing for both chambers, dual chamber activity sensing, and dual response (triggering and inhibition); LV, left ventricular

2.4. Patient 4

Seven years ago, a 49‐year‐old woman with rheumatic heart disease and AF underwent mitral valve, tricuspid valve, and aortic valve replacement with mechanical prostheses. Six months later, the patient experienced syncope. Intermittent third‐degree AV block with permanent AF was documented during a 24‐h recording, which made pacemaker implantation necessary. A bipolar endocardial pacing lead (Medtronic 4194) was implanted into an anterolateral branch of the CS (Figure 4). The lead was connected to a single‐chamber pacemaker located subpectorally. Measurements at implantation were as follows: R wave of 8.6 mV, ventricular threshold of 1.7 V at 0.4 ms, and impedance of 876 Ω.

Figure 4.

Implantation procedure of LV lead through CS. In (A) and (B) the black arrow shows the anterior‐lateral vein of CS demonstrated by angiography. In (C) and (D), the red, yellow, and white arrows indicate the mechanical tricuspid, mitral, and aortic valves, respectively. The green arrow shows that the LV lead is in the anterior‐lateral vein of CS. Abbreviations: CS, coronary sinus; LV, left ventricular

3. DISCUSSION

In South China, rheumatic heart disease is a common disease, especially among women. We studied 4 cases of women with rheumatic heart disease who accepted mitral and tricuspid or aortic valve replacement, and were all bradycardic requiring pacemaker implantation. In all 4 cases, LV pacing through the CS appeared feasible and yielded satisfactory results at long‐term (≥1 year) follow‐up, with stable pacing thresholds and no lead dislodgement noted. In terms of optimal lead positioning, the current experience would suggest that the LV lateral wall is of minimal importance, whereas capture threshold, sensing amplitude, and impedance at implantation must be satisfactory.

The implantation of a pacemaker in the presence of tricuspid valve prosthesis needs to be discussed. Many authors strongly oppose endovascular implantation. With the presence of tricuspid valve intervention, RV lead implantation is associated with the potential risk of tricuspid valve malfunction, leading to tricuspid regurgitation or the high possibility of inaccessibility of the RV. Specific mechanisms have been postulated, including perforation or laceration of valve leaflets, direct lead interference with valve closure, or adherence of the lead to the tricuspid valve. Furthermore, in patients undergoing tricuspid valve surgery, the presence of a transvenous pacemaker implanted either preoperatively or within 30 days of surgery is associated with a significantly increased risk of persistent or recurrent tricuspid regurgitation.2

Some authors have reported on LV pacing with epicardial lead implantation on the diaphragmatic surface of the RV, requiring a small thoracotomy.4 Despite good results and low complication rates, this technique involves the major disadvantage of general anesthesia and surgical incision in patients who have already undergone cardiac operations; ventricular tissue is adherent, with a risk of ventricle injury during dissection.

The use of ventricular pacing through the CS in patients with tricuspid prosthesis seems to provide effective pacing and sensing measurements, with a minimally invasive approach. This method, which was first described by Bai and colleagues in 1994,5 has been modified over time by several authors.6, 7, 8 The most common complications of this technique are diaphragmatic stimulation, CS dissection, lead dislodgement, and high pacing threshold. However, development of cardiac resynchronization therapy using biventricular pacing led to use of new guiding catheters and leads as a transvenous route for LV pacing, with an increased success rate of up to 99%. Even so, we must admit that pacing issues, including dislodgement with capture failure, are significantly higher with CS compared with RV leads. So, LV pacing with CS alone may not be an appropriate pacing method for patients who are or are likely to become pacing‐dependent. In view of this, it is also worth highlighting that the use of active‐fixation CS leads (such as the Medtronic 4195 used in this series) may be preferable to using passive CS leads.

3.1. Study limitations

The present study is limited by its retrospective, single‐center, case‐series design with a small sample size.

4. CONCLUSION

LV pacing through the CS appeared safe and efficacious with stable measurements, which would bode favorably for its use as first choice for patients with a prosthetic tricuspid valve who require implantation of a device for permanent stimulation. Further study is warranted.

Author contributions

The first 3 authors contributed equally to the study.

Conflicts of interest

The authors declare no potential conflicts of interest.

Zha K, Cui K, Liu X, Fang Y. Clinical investigation of left ventricular pacing using coronary sinus in patients with mechanical prosthetic tricuspid valve replacement. Clin Cardiol. 2017;40:1139–1144. 10.1002/clc.22800