CRT Case-Based Troubleshooting

黃金隆台中榮總

心臟血管中心THRS CIED PHYSICIAN TRAINING

COURSE

Troubleshooting

• CS: Inability to engage, dissecting.• Extra-cardiac stimulation: PNS.• Pacing failure.• Inadequate bi-ventricular pacing.• Upgrade to CRT-right side approach.• SVT vs VT• Responders.

Inability to engage, dissecting

Anatomy of CSAnatomy of CSRAO

AP

LAO

Steep LAO: 400

Left sided implants: Operator should

stand on right side

EP GuideEP Guide

Where is the orifice of CS

Tricuspid Annulus & CS OrificeTricuspid Annulus & CS Orifice

AP view + EP electrograms of CS

AP view + EP electrograms of CS in AF

CRT implantation- How to engage CS by EP

catheter

Case 1

A 63 yr man was a case of dilated cardiomyopathy with VT and wide QRS duration and low LVEF= 20 %.

He was suggested to receive cardiac resynchronization therapy to improve his heart failure.

CRT implantation- CS engagement by EP

catheter

CS angiography

Acute angle of LCV

How to do it ?

Subselective catheter

CS dissecting

How to manage this situation ??

Final position of LV lead

CS Dissection

Contak CD study: perforation or dissection of the coronary sinus in 1.8% and extra cardiac stimulation of 1.6%.

Management: Surgical approach Delay the LV lead implantation after 2

weeks Select another cardiac vein

Repeat venography after CS dissection

Antero-lateral cardiac vein

Final Position of LV lead (RAO 200)

PNS not found during the implantation but occurred during OPD F/U ??

PS implications in CRT

Author(year)

Cathodeprogramma

bility

Intra-operativeLV lead

repositioning

PS at f/uLV lead

replacement

PS-related

CRT failure

Gurcwitz et al. (2005) 47% NA 11% 13% 2%　Cathode

programmbility 100% NA 9% 0% 0%

　No cathode programability 0% NA 16% 24% 4%

Biffi et al. (2009) 29% 3% 24% (14% symptomatic) 5% 2%

　Cathode programmbility 100% 0% 13% (10%

symptomatic) 0% 0%

　No cathode programability 0% 9% 28% (18%

symptomatic) 7% 3%　　 　 　 　 　 　Seifert et al. (2010) 30% 10% 33% (9%

symptomatic) 1% 0%

Incidence of PNS in different locationsIncidence of PNS in different locations

PNS frequently at middle–

lateral/posterior,

apical LV sites

Biffi et al. Europace. 2012 Jul 29

Supine Left lateral Sitting

Phrenicthreshold(V@0.4ms) 4.430.9 3.511.2 4.071.9

LVthreshold(V@0.4ms) 1.070.6 1.090.5 1.110.6

Seifert et al : PS 0.9 V lower in left lateral vs supine at FU

LV pacing : TIP to RV Coil/ring

70% of PS-related lead repositionings occurred at this site Seifert et al. Europace (2010) 12, 961–967

To AVOID SEVERE ISSUES

≥ 3V IS NEEDED atA PS-LV safety marginlong term because of

- LV THRESHOLD FLUCTUATIONS- PS THRESHOLD POSTURAL CHANGES

Guidewire method

Case 1

EP catheter guide engagement CS dissecting during acute angle. PTCA wiring to find new route Post implantation PNS could be

managed by the change of vector. Multi-electrode LV lead provided

multiple choices.

中央健保局 植入心臟再同步化節律器的相關規定 (98.07.01)

• ( 一 ) 應事先審查。 • ( 二 ) 正常竇房節心律，左心室搏出分率≦ 35%，且左側支束傳導完全阻滯， QRS 波的寬度≧ 120 毫秒，紐約心臟學會功能分級是第三級或者第四級經適當藥物治療仍不能改善之病患。 • ( 三 ) 心房顫動之病患，左心室搏出分率≦ 35%，且左側支束傳導完全阻滯， QRS 波的寬度≧ 120 毫秒，紐約心臟學會功能分級是第三級或者第四級經適當藥物治療仍不能改善之病患。 • ( 四 ) 心室節律器依賴之病患，左心室搏出分率≦ 35%，紐約心臟學會功能分級是第三級或者第四級經適當藥物治療仍不能改善之病患。

Case 2

• A 84 yr male patient is a case of DCM,AF CLBBB, CHF Fc IV

• Frequent admission due to pul edema and rapid atrial fibrillation.

• CRT-P implantation.

Class IIa: AF + CHF 1.Is it necessary to implant RA lead? 2.Routine AV node ablation ?

CHF + Chronic AF

CHF + Chronic AF (Mrs. Chang CJ)

2008.01.15 2009.11.13

Chronic AF

2 years later

How can we do if no RA lead ?

Spontaneous conversion to SR

(2010.02.26)

Transient turn-off the CRT

RA lead in chronic AF

Case 3

• A 65-year-old woman: DCM,PAF +VT s/p CRT-D on 2013/10/16, CHF Fc IV LVEF: 14%.

• Peri-procedure complication .• Rapid atrial fibrillation

Pre- CRT

Cardiomegaly

CS engagement

What will happen ?

CS Dissecting

Initial slow injection/test dose is suggested!

Guide-wire approach

0.014 PTCA wiring !

LV lead

After CRT-D

Poor Bi-ven during rapid AF

Low Bi-ventricular pacing rate %

Bi-ven after medication

Case 2,3

• RA lead is suggested in chronic AF.• Initial test injection is prefered• PTCA wire during the CS dissecting• Rate control is necessary during rapid AF.

Effect of CRT on conversion of persistent AF to sinus rhythm.

Becher et al. Clin Res Cardiol. 2009 ;98(3):189-94 • 46 with persistent AF (> or =4 wks pre-implant), QRS

> 130 ms, LVEF <0.35, NYHA III or IV heart failure. • During 22 +/- 9 (7-34) ms of follow-up, 8 out of 46

patients (17%) converted to SR. • Echo: LVEF,LA diameter did not differ significantly • Pts converting to SR showed a significant reduction in

systolic PA pressure on CRT vs. before CRT (45 +/- 13 vs. 29 +/- 5 mmHg, P = 0.008).

RA lead is necessary !!

Does AF preclude biventricular pacing?AF/SR No. of AF patients

with AVN ablationFU Echo and

clinical benefit by

CRT

Favourable outcome in AF patients with AVN ablation

Molhoek 30/30 17(57%) before CRT 25m AF=SR No difference

Delnoy 96/167 21(22%), only 2 with pacing <50% after

CRT

22.9m AF=SR Not mentioned

Leclercq 15/22 15(100%) 14.4m AF=SR Not applicable

Gasparini 162/349 114(70%) if pacing <85%

34m AF+AVN=SR Yes

Khadjooi 86/209 0 81.6 AF=SR Not applicable

Fung JW. Heart 2008 94(7):826-7. It is not necessary to do the routine AV node ablation.

Class IIa: CHF + Pacing dependent

1.Pre-existing PPM.2.How to tx the venous occlusion?

A

B

Case 4. Cardiac sarcoidosis with AV block s/p VVI

A

B

Su, Huang et al. Sinica Cardiologica 2009

The tough thing while upgrading from pacemaker to CRT ?

Occlusion of SCV

Epicardial approach (n=5) Right side approach (n=26)

Epicardial approach needs general anesthesia and recovery time

Guidewire method

Case 5: Upgrade of PPM to CRT

Case 4,5

Upgrade from PPM to CRT Opposite site approach is preferred Guidewire method is prefered

Case 6 Name: Wang XX Age: 89 year-old Sex: Male BW: 64 kg: BH: 164 cm C.C.: Dyspnea on exertion,

orthopnea and PND for more than one year

Brief History (1) A 89-year-old man

Ischemic cardiomyopathy, NYHA Fc III-IV, LVEF: 22%. CLBBB with QRS duration of 200 ms.

Refractory to optimal medical treatment : Aspirin, Carvedilol, Fosinopril

Underlying diseases: CAD-I (LAD) s/p POBA + BMS in 2009 HCVD Type 2 DM PAOD, s/p PTA Chronic renal insufficiency

CXR

Mar. 22, 2010

•Cardiomegaly

•Interstitial edema

•Pleural effusion

ECG

NSR, CLBBB, QRS duration : 200 ms

CRT Implantation May 27th ,2010-

CS VenogramBig Target vein

Which lead is prefered

CRT Implantation-leads Positioned over RV, LV (4194 6F)

and RAMay 27, 2010

LAO 60° AP view

ECG s/p CRTECG s/p CRT

NSR, Bi-V pacing with narrow QRS

May 27 s/p CRT

May 31

Baseline

What happen ??

CXR

Dislodgement of LV lead to RA

May 27 May 31

LV lead re-implantation Procedure: Not necessary to do

another needle venopucture, just Re-introducing a PTCA

wire over the LV lead Retrieve the LV lead Re-advancing a long

sheath and engage to CS

Re-implant LV lead to LCV.

Jun 01,2010

0.014" guide wire

Changing a new Lead, Starfix lead in the same branch

ECG post LV lead re-implantationECG post LV lead re-implantation

NSR, Bi-V pacing with narrow QRS

It is useful to fix the LV lead in the target vein by Starfix

lead

an active-fixation LV lead (4195 unipolar)

showed a 15.3% PNS

occurrence atfollow-up.

Biffi et al. Europace. 2012 Jul 29

Larger diameter lead to match lead-vein diameter ?

Case 7 Name: Mr. Lee Age: 74 year-old Sex: Male BW: 65 kg: BH: 172 cm C.C.: General weakness and

dyspnea for two weeks.

Brief History (1) A 74-year-old man

Ischemic cardiomyopathy, NYHA Class IV, LVEF: 26%

CLBBB with QRS duration of 164 ms . Comorbidities:

CAD-III s/p PCI with stenting. HCVD Type 2 DM Old pulmonary TB BPH COPD

ECG

Af, CLBBB, QRS:164 ms

CS Venography

Lat Marginal Cardiac vein, but acute angle

LV lead position after CRTLV lead position after CRT

AP view LAO 600 view

Attain Select® II

Suboptimal position

LV lead dislodged 10 minutes after CRT

Redo CS Angiography

Another choice to MCV

Starfix lead not available—cannulate another branch-

MCV

Case 6,7Case 6,7

It is not all necessary to match lead-vein size.

Small caliber lead with deep insertion is suggested.

In the acute angle vein, try another cardiac vein.

Case 8: Stable became unstable

83-year-old woman : DCM, CHF NYHA Fc IV, CLBBB and VT, s/p CRT-D on 2009/11/05, FC II-I –Good response.

LVEF=30%- 62%

Good response

LVEF=62%LVEF=62%

SOB occurred

Lead status

Unstable OptiVol

Case 8

Lead status should be monitored periodically.

Change from stable to unstable situation implied something wrong.

Case 9: SVT vs VT

Sudden onset Sudden onset

SVT DxSVT Dx

Case 10

A 60 yr male, DCM with CHF, NYHA Fc III and Af with CLBBB, sudden collapse s/p resuscitation S/P CRT-D implantation .

Several episodes of shock Progressive dyspnea

Atrial under sensing

Where is the marker

Serial ECGSerial ECG

Amiodarone for PAF

Widen QRS during bi-v pacing

Widen QRS

Adjust the AV interval

AV Delay Optimization Methods

Too short AVToo short AV Too long AVToo long AV ““Just Right” AVJust Right” AV

E and A waves E and A waves separated, separated,

but A wave is truncatedbut A wave is truncated

E A

E and A waves E and A waves fused,fused,

but DFT reduced but DFT reduced

E AE

A

E and A waves E and A waves separatedseparated

and DFT mantainedand DFT mantained

Adjust the AV =350 msec

Case 9,10

Differential dx of tachycardia from SVT vs VT.

Interrogation is necessary to evaluate the lead status and local electrograms

Individual optimization of AV interval.

Predicting Response to

CRT

Patient SelectionEvidence of dyssynchro

ny

Adequate lead

placement

Atrial fibrillati

on

Perisistent mitral

regurgitation

Cardiac ischemi

a

Prerenal

azotemia

Increased nonresponder rate

Huge scar !!

Integration of Anatomical and Functional Evaluation

JACC Cardiovasc Imaging. 2014 Dec;7(12):1239-48

Integration of Anatomical and Functional Evaluation

Scar burden

Latest activation

Coronary sinus accessibility

Integration of Anatomical and Functional Evaluation

Scar burden

Latest activation

Coronary sinus accessibility

Integration of Anatomical and Functional Evaluation

Latest activation

Coronary sinus accessibility

Scar burden

Case 11

• A 53 yr male patients with DCM, CLBBB, CHF Fc III with LVEF=30%.

• Medication for one year.• Condition did not improved

LV sites selection

Early onset of electrical reverse remodeling

Conclusion

• CS: engaged by EP guide or guidewire method, dissecting find another way.

• Extra-cardiac stimulation: PNS—multi-electrode lead.

• Pacing failure: dislodge or scar • Inadequate bi-ventricular pacing: rate control

esp in the rapid AF• SVT vs VT differentiation• Lead status

Thank you for your attention !!