A successful placement of the left ventricular lead for the cardiac resynchronization device using the orthodromic snare technique: clinical case

Abstract

Background: The main aim of Cardiac Resynchronization Therapy (CRT) is a positive response of the patient, particularly, reduction of the symptoms and improvement of the heart contractility, that can be reached in 50–70% of patients. The possibility of appropriate positioning the left ventricular (LV) lead is of great importance for the response to CRT. Certain instruments and technical approaches are used for the placement of the LV lead. Here, we describe the use of the orthodromic snare technique, which is quite rare in practice, but allows one to overcome some anatomical obstacles.

Clinical case description: Patient A., suffering from the heart failure with a low ejection fraction and left bundle branch block, was admitted to the hospital for CRT implantation. Before the operation, all the necessary routine instrumental and laboratory diagnostics was performed. During the operation, venography of the cardiac veins revealed unsuitability of the lateral cardiac vein for the placement of the LV lead due to its very small diameter. The posterolateral vein was suitable for the LV lead implantation but still had some anatomical difficulties: an acute angle of inflow and local stenosis in the proximal segment. During the procedure, the following techniques were used without success: positioning the LV lead by a simple translational movement forward, a subselective catheter, introduction of several coronary guides in order to smooth out the acute angle of inflow. These circumstances warranted the use of the orthodromic snare technique for a successful LV lead placement.

Conclusion: This clinical case illustrates the possibility of a safe and effective use of the orthodromic snare technique for LV lead implantation. Such anatomical difficulties as a small diameter, acute angle of inflow, local stenosis have also been illustrated and discussed.

Keywords

clinical case / cardiac resynchronization therapy / heart failure

References

[1] Sieniewicz BJ, Gould J, Porter B, et al. Understanding non-response to cardiac resynchronisation therapy: common problems and potential solutions. Heart Failure Rewies. 2019;24(1):41–54. doi: 10.1007/s10741-018-9734-8

[2] Leyva F, Nisam S, Auricchio A. 20 Years of cardiac resynchronization therapy. J Am Coll Cardiol. 2014; 64(10):1047–1058. doi: 10.1016/j.jacc.2014.06.1178

[3] Singh JP, Klein HU, Huang DT, et al. Left ventricular lead position and clinical outcome in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT) Trial. Circulation. 2011;123(11):1159–1166. doi: 10.1161/CIRCULATIONAHA.110.000646

[4] Stoia MA, Istratoaie S, Pop S, et al. The importance of lead positioning to improve clinical outcomes in cardiac resynchronization therapy. In: Cardiac Diseases and Interventions in 21st Century; December 11th, 2018. doi: 10.5772/intechopen.85488

[5] Pothineni NV, Supple GE. Navigating challenging left ventricular lead placements for cardiac resynchronization therapy. J Innov Cardiac Rhythm Manage. 2020;11(5):4107–4117. doi: 10.19102/icrm.2020.110505

RIGHTS & PERMISSIONS

Dubrovin O.L., Shugaev P.L.