Endocardial left ventricle lead implantation for cardiac resynchronisation therapy: An Australian experience.

Introduction: Cardiac resynchronisation therapy (CRT) is an established therapy for symptomatic patients with advanced heart failure. However, traditional left ventricular lead placement may not always be technically feasible via the coronary sinus approach. Left ventricular (LV) endocardial lead implantation via a transseptal atrial approach may be a potential alternative. Purpose(s): We sought to review the feasibility and clinical outcomes in patients undergoing LV lead implantations in a single-centre, tertiary, Australian institution. Endpoints included: technical success, peri-procedural complication rates, percent LV pacing load, change in New York Heart Association (NYHA) class and change in LV ejection fraction (LVEF). Method(s): and Results: Between August 2015 and December 2016, four patients underwent endocardial LV lead implantation (3 males, mean age 71 +/-5 years). All patients had previously failed LV lead placement via the coronary sinus. Mean pre-procedural LVEF was 24 +/-8%, mean QRS duration 161+/- 19ms and baseline NYHA was III (n=3) and IV (n=1). All patients had existing indications for therapeutic anticoagulation and were anticoagulated with warfarin (3 for atrial fibrillation, 1 for mechanical aortic valve). Warfarin was withheld for 3 days prior to the procedure. Mean international normalized ratio (INR) at the time of the procedure was 1.6+/-0.3. LV access was via an inferior approach, using femoral transseptal access, with a snare from superior subclavian venous access providing access to the left atrium. The lead was then inserted via the deflectable guiding sheath into the lateral LV endocardial wall. Successful implantation was achieved in all patients. One patient had a thromboembolic complication (non disabling stroke) post procedure, despite an INR of 2.1 at the time. That patient subsequently died from progressive heart failure within a month of the procedure. The 3 remaining patients have a mean follow up of 10 +/-7 months. The me