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CASE REPORT  
Year : 2012  |  Volume : 15  |  Issue : 3  |  Page : 229-232
TEE-guided left ventricular epicardial pacing lead placement for cardiac resynchronization therapy


1 Department of Cardiac Anaesthesia, Hero DMC Heart Institute, Ludhiana, Punjab, India
2 Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India
3 Department of Cardiovascular and Thoracic Surgery, Hero DMC Heart Institute, Ludhiana, Punjab, India

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Date of Submission14-Oct-2011
Date of Acceptance17-Jan-2012
Date of Web Publication4-Jul-2012
 

   Abstract 

Biventricular pacing has demonstrated improvement in cardiac functions in treating congestive cardiac failure patients. Recent trials have proven the clinical and functional benefits of cardiac resynchronization therapy in severe heart failure and intraventricular cardiac delays, mainly left bundle branch block. Biventricular pacing improves the exercise tolerance, quality of life, systolic heart function, reduces hospitalization and slows progression of the disease. A 54-year-old lady, a known case of dilated cardiomyopathy, was on biventricular pacing since 2 years. She presented in emergency with sudden deterioration of dyspnea to NYHA class III/IV. When investigated, the coronary sinus lead was found displaced; thus, left ventricle (LV) was not getting paced. After multiple failures to reposition the coronary sinus lead, it was decided to surgically place the epicardial lead for LV pacing under general anesthesia. Lateral thoracotomy was done and LV pacing lead was placed at different sites with simultaneous monitoring of cardiac output (CO) and stroke volume (SV) by transesophageal echocardiography (TEE). Baseline CO and SV were 1.9 l/min and 19.48 ml respectively and increased at different sites of pacing at LV, the best CO and SV were 4.2 l/min and 42.39 ml respectively on lateral surface. Intraoperative TEE can calculate beat to beat stroke volume and thus CO and helps to choose optimal site for placement of epicardial pacing lead.

Keywords: Cardiac resynchronization therapy, Dilated cardiomyopathy, Epicardial pacing, Transesophageal echocardiography (TEE)

How to cite this article:
Arya RC, Sood NK, Ralhan S, Wander GS. TEE-guided left ventricular epicardial pacing lead placement for cardiac resynchronization therapy. Ann Card Anaesth 2012;15:229-32

How to cite this URL:
Arya RC, Sood NK, Ralhan S, Wander GS. TEE-guided left ventricular epicardial pacing lead placement for cardiac resynchronization therapy. Ann Card Anaesth [serial online] 2012 [cited 2019 Nov 15];15:229-32. Available from: http://www.annals.in/text.asp?2012/15/3/229/97979



   Introduction Top


Biventricular pacing has demonstrated improvement in cardiac functions in congestive cardiac failure patients. The Miracle trial [1] has proven the clinical and functional benefits of cardiac resynchronization therapy (CRT) in severe heart failure due to intraventricular cardiac delays, mainly left bundle branch block (LBBB). Biventricular pacing improves the exercise quality of life, systolic heart function, reduces hospitalization and slows progression of the disease. A 54-year-old lady, known case of dilated cardiomyopathy (DCM), was on biventricular pacing since 2 years. Epicardial pacing was performed in the patient because of the displacement of coronary sinus lead. We describe site selection for the placement of epicardial lead by measuring cardiac output (CO) measured by transesophageal echocardiography (TEE).


   Case Report Top


The patient presented for the first time 2 years back with a history of dyspnea NYHA class III/IV. ECG recorded at that time showed LBBB and transthoracic echocardiography showed severe left ventricular (LV) dysfunction. The echocardiography report showed DCM (LV internal diameter were: 76 mm and 70 mm in diastole and systole, respectively) with ejection fraction 18-20%, severe mitral regurgitation and mild tricuspid regurgitation apart from global hypokinesia. A significant interventricular and intraventricular dysynchrony was found as calculated by (i) Q wave on ECG to aortic valve opening time (Q-AV) 180 ms, and Q wave to pulmonary valve opening time (Q-PV) 100 ms, (ii) interventricular mechanical dysynchrony (IVMD) 180-100 = 80 ms and (iii) intraventricular dysynchrony depicted by septal posterior wall motion delay (SPWMD) 260 ms. Coronary angiogram was performed, which showed normal coronary arteries.

A permanent pace maker (Medtronic Insync III 8042, Medtronic Corporation, Mineapolis MN 55432, USA) was placed at that time. Right atrial lead was placed in the right atrial appendage, right ventricular lead was placed in its cavity and LV lead was placed in the coronary sinus. Dual chamber, atrial sensing and bi-ventricular pacing was done. The pacing data for different leads are given in [Table 1]. She was advised to continue with diuretics, digoxin and ACE inhibitor drugs and her symptoms improved to NYHA class II.
Table 1: Details of endocardial pacing

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Presently, she presented with sudden worsening of dyspnea from NYHA class II to class IV. On investigations with the help of an interrogation device, it was found that the pacing lead placed in the coronary sinus was displaced and was not pacing. The patient was taken to the cardiac catheterization laboratory where multiple attempts to replace the coronary sinus lead were unsuccessful. It was planned to place the LV pacing lead surgically on the epicardial surface.

The patient was anesthetised with fentanyl and propofol and rocuronium was used to facilitate intubation with a cuffed endotracheal tube. Routine monitoring as for any other cardiac surgical patient was done. TEE probe was placed (HP Sonos 5500, Omniplane TEE probe) and routine comprehensive TEE examination was done [Figure 1], which confirmed the preoperative echocardiography findings. CO was measured at the level of left ventricular outflow tract (LVOT) [Figure 2]. Transgastric long axis view was chosen to measure the velocity time integral (VTI) across the LVOT [Figure 3] and then CO was calculated by applying the following formula:

CO = {22/7 × (D/ 2 ) 2} × VTI × HR

(where D is the diameter of LVOT and VTI is the velocity time integral across LVOT)
Figure 1: Midesophageal four-chamber view showing dilated left ventricle

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Figure 2: Midesophageal aortic long axis view (137*) showing measurement of left ventricular outflow tract diameter

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Figure 3: Transgastric long axis view (pulse wave Doppler) showing baseline velocity time integral calculation across the left ventricular outflow tract

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(Doppler angle correction was not applied as there was good alignment of Doppler beam and blood flow with angle less than 20 degree.)

Initially, the operating surgeon made a subcutaneous tunnel from the implanted site of the previous pacemaker, right subclavian pocket, to left thoracotomy incision site, and passed the pacing lead from the pacemaker to the left lateral chest wall; thereafter, right lateral position was given and left thoracotomy was performed. After opening the pericardium, the surgeon placed the pacing lead at different parts of the LV. During each placement, we calculated the stroke volume and CO by TEE, The results of pacing at different sites are given in [Table 2]. The baseline CO was 1.9 L/min. The CO ranged from 3.2 L/min at the anterior surface to a maximum of 4.2 L/min [Figure 4] on the lateral surface. After achieving the best CO at the lateral surface, the lead was fixed at that point and the chest was closed. The patient was extubated after 4 h, once she met the criteria for extubation and was hemodynamically stable.
Figure 4: Transgastric long axis view (pulse wave Doppler) showing velocity time integral across the left ventricular outflow tract after final epicardial lead placement

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Table 2: Measurement of various hemodynamic parameters during placement of pacing leads on various positions on the left ventricle

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CRT is a well-documented practice in DCM patients. In the Miracle trial [1] (453 patients), combined risk of death or worsening of heart failure was significantly lower in the CRT group as compared with the control group. To achieve optimal benefits of CRT, accurate multisite pacing is necessary. To optimize CRT, the most difficult part is placement of LV lead for biventricular pacing. LV pacing can be done by either placing the lead in the coronary sinus or directly on the epicardial surface surgically. For epicardial LV lead, it has to be placed at a point where optimal concordance is achieved between the pacing site and the site of most delayed LV mechanical activation. Dekker et al.[2] reported that mapping to determine the best pacing site is a prerequisite for placement of epicardial lead to optimize CRT. They used pressure-volume loops to real-time guidance for targeting epicardial lead placement during minimal invasive surgery.

Since past few years, TEE has been extensively used perioperatively in cardiac operation rooms and had achieved a significant place as a diagnostic as well as a monitoring tool. The CO measured by TEE has been validated extensively by various studies and is comparable with the thermodilution method used with a Swan Ganz PA catheter. [3]

In a study conducted by Mair et al.,[4] epicardial pacing lead was placed in 16 patients (seven electively and nine due to failure of placement of coronary sinus lead). Chronic threshold capture of surgically placed LV leads was significantly lower in all controls. Compared with coronary sinus leads, the surgically placed LV leads had significantly less LV lead-related complications. For selection of site of lead placement, intraoperative mean QRS-duration was measured to assess the success. In our case also, the need for placement of epicardial lead was displacement of previously placed coronary sinus LV lead.

To summarize, intraoperative TEE provides an alternate method to assess the site for placement of epicardial LV lead for CRT. With TEE, the optimal results of CRT were achieved by quantitative assessment of stoke volume and CO. Thus, the CO measured by TEE is a good guide for the selection of the site for the epicardial lead placement.

 
   References Top

1.Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med 2002;346:1845-53.   Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2. Dekker AL, Phelps B, Dijkman B, van der Nagel T, van der Veen FH, Geskes GG, et al. Epicardial left ventricular lead placement for cardiac resynchronization therapy: Optimal pace site selection with pressure-volume loops. J Thorac Cardiovasc Surg 2004;127:1641-7  Back to cited text no. 2
    
3.Bródka J, Tu³ecki £, Ciurysek M, Gburek T. Thermodilution vs transesophageal echocardiography for cardiac output measurement in patients with good left ventricle function. Anestezjol Intens Ter 2010;42:15-8.  Back to cited text no. 3
    
4.Mair H, Sachweh J, Meuris B, Nollert G, Schmoeckel M, Schuetz A, et al. Surgical epicardial left ventricular lead versus coronary sinus lead placement in biventricular pacing. Eur J Cardiothorac Surg 2005;27:235-42.  Back to cited text no. 4
    

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Correspondence Address:
Rajesh Chand Arya
Department of Cardiac Anaesthesia, Hero DMC Heart Institute, Unit Dayanand Medical College and Hospital, Civil Lines, Ludhiana, Punjab - 141 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.97979

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]

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