Biventricular Pacemaker Implantation in a Patient with Superior Vena Cava Occlusion

DOI: 10.19102/icrm.2013.040608

¹LEA El HAGE, MD, ²COLLEEN J. JOHNSON, MD and ¹NITISH BADHWAR, MBBS

¹ Department of Medicine (Division of Cardiology), University of California, San Francisco, CA
² Department of Medicine (Division of Cardiac Electrophysiology), Tulane Heart and Vascular Institute, New Orleans, LA

Download PDF

Follow Us >> Tweet

ABSTRACT. Cardiac resynchronization therapy has been shown to improve quality of life and mortality in patients with heart failure. Patients referred for device upgrade may present with an occluded superior vena cava. We describe a technique using a stylet through a left ventricular lead to cannulate the coronary sinus and overcome the occlusion. This technique had no complications and resulted in successful placement of the left ventricular lead with good capture and pacing thresholds.

KEYWORDS. biventricular pacemaker, superior vena cava occlusion.

The authors report no conflicts of interest for the published content.
Manuscript received February 11, 2013, Final version accepted April 23, 2013.

Address correspondence to: Nitish Badhwar, MBBS, 500 Parnassus Avenue, MUE-431 San Francisco, CA 94143-1354. E-mail: badhwar@medicine.ucsf.edu

Introduction

Patients with advanced heart failure (New York Heart Association (NYHA) class III or IV), left ventricular systolic ejection fraction (LVEF) less than 35% and a QRS duration of at least 120 ms have shown improvement in the quality of life and mortality with cardiac resynchronization therapy (CRT).^1,2

Approximately 7% of asymptomatic patients with previous devices planned for upgrade have a subtotal or complete occlusion of the subclavian vein.³ Various venoplasty techniques have been used to overcome the occlusion. We describe a technique using a stylet through a left ventricular (LV) lead to cannulate the coronary sinus (CS) and overcome a total superior vena cava (SVC) occlusion.

Case

A 73-year-old male with a history of ischemic dilated cardiomyopathy, status post coronary artery bypass graft surgery, atrial fibrillation, and a previous pacemaker implantation was referred for an upgrade to a biventricular pacemaker. The patient had advanced heart failure (NYHA class III) despite optimal medical therapy. A baseline 12-lead electrocardiogram (ECG) showed a right ventricular (RV) paced QRS complex with duration of 166 ms (Figure 1). An echocardiogram showed a LVEF of 25%.

The left axillary vein was cannulated using a micropuncture technique. It was noted that there was difficulty advancing the guidewires at the junction of the left subclavian vein and the SVC (Figure 2). Neither the CS sheath nor catheter would advance beyond the stenosis at the junction of the subclavian vein and SVC. Injection of radioconstrast dye confirmed subtotal occlusion at this site.

At this point, a 0.014-mm Whisper wire was advanced to the inferior vena cava. It was then possible to advance a Ventura catheter over the Whisper wire. Despite the Ventura catheter, the Whisper wire would not cannulate the CS. Hence, the Ventura catheter was removed and the LV pacing lead (St. Jude Medical model number 1158T) was advanced over the Whisper wire into the right atrium. Subsequently, the Whisper wire was removed and a stylet was placed into the LV lead. The stylet was shaped with a wide curve (Figure 3) and placed in the LV lead to cannulate the CS. After cannulating the CS, the LV lead was advanced into the CS and placed in a posterior lateral branch vein using the stylet and the natural curve of the lead (Figure 4). Adequate pacing and sensing thresholds were obtained and lack of diaphragmatic stimulation at high input was noted. Despite the difficulty with lead placement, narrowing of the baseline QRS was obtained as seen on the 12-lead ECG taken post procedure (Figure 5). The patient showed improvement in clinical symptoms over a follow-up period of 15 months.

Discussion

Subtotal occlusion of the SVC is occasionally noted in patients referred for device upgrade. Venoplasty techniques to overcome SVC occlusions include balloon venoplasty,⁴ microdissection,⁵ excimer laser photoablation,⁶ or the use of a hollow tube with screw-like tip to rotate through the occlusion.⁷ Complications of these mechanical techniques include barotrauma, perforation, and bleeding with misdirection, especially if venoplasty is performed after such misdirection.⁸

The transfemoral approach is another technique used to overcome such occlusions.⁹ Complications with this technique include infections, phlebitis, lead displacement, deep venous thrombosis, and. rarely, pulmonary embolism.⁹ Surgical techniques include epicardial lead placement, transatrial approach via median sternotomy, or a limited right parasternal mediastinotomy.^10–12 These techniques require invasive surgery and often result in early lead degradation. The risk is even higher in patients with previous sternotomy, which was the case in our patient.

Given the complications of the aforementioned techniques, traditional placement of the LV lead if at all possible is the most desirable choice. In our technique, the stylet was curved to match the CS cannulating sheath. This, along with the natural curve of the LV lead helped subselect the branch vein leading to successful placement of the LV lead with no complications and good capture and pacing thresholds. This technique may have limitations in that not all LV lead types can cannulate the CS lead. This can be expensive due to the cost of the LV lead if this technique is not successful.

Conclusion

In the event of SVC occlusion, we propose the use of a curved stylet within the LV lead as an alternative and safe technique to cannulate the CS and pace the LV.

References

1. Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med 2002; 346:1845–1853. [CrossRef] [PubMed]
2. Jarcho JA. Biventricular pacing. N Engl J Med 2006; 355:288–294. [CrossRef] [PubMed]
3. Saxon LA, Ellenbogen KA. Resynchronization therapy for the treatment of heart failure. Circulation 2003; 108:1044–1048. [CrossRef] [PubMed]
4. Moukabary T, Thai H, Thal S. Subclavian balloon venoplasty to facilitate lead implant in patient with subclavian venous obstruction. J Invasive Cardiol 2011; 23:E83–85. [CrossRef] [PubMed]
5. Worley SJ, Gohn DC, Pulliam RW. Needle directed re-entry to cross a subclavian occlusion following failed microdissection. Pacing Clin Electrophysiol 2007; 3:1562–1565. [CrossRef] [PubMed]
6. Worley SJ, Gohn DC, Pulliam RW. Excimer laser catheter to cross a subclavian occlusion after failed microdissection. Heart Rhythm 2008; 5:469–471. [CrossRef]
7. Worley SJ, Gohn DC, Pulliam RW. Opening an occluded subclavian vein with a screw-like flexible hollow guide-wire and venoplasty. Pacing Clin Electrophysiol 2007; 30:1290–1293. [CrossRef] [PubMed]
8. Charalambous N, Schafer PJ, Trentmann J, et al. Percutaneous intraluminal recanalization of long, chronic superficial femoral and popliteal occlusions using the Frontrunner XP CTO device: a single-center experience. Cardiovasc Intervent Radiol 2010; 33:25–33. [CrossRef] [PubMed]
9. Barakat K, Hill J, Kelly P. Permanent transfemoral pacemaker implantation is the technique of choice for patients in whom the superior vena cava is inaccessible. Pacing Clin Electrophysiol 2000; 23(Pt 1):446–449. [CrossRef] [PubMed]
10. Goldstein DJ, Rabkin D, Spotnitz HM. Unconventional approaches to cardiac pacing in patients with inaccessible cardiac chambers. Ann Thorac Surg 1999; 67:952–958. [CrossRef] [PubMed]
11. Byrd CL, Schwartz SJ. Transatrial implantation of transvenous pacing leads as an alternative to implantation of epicardial leads. Pacing Clin Electrophysiol 1990; 13(Pt 2):1856–1859. [CrossRef] [PubMed]
12. Stys T, Kapoor S, Carter-Adkins D, Pachulski RT. Innovative endovascular defibrillator lead use in superior vena cava obstruction. J Interv Card Electrophysiol 2002; 6:87–89. [CrossRef] [PubMed]