Cryoballoon Ablation for Persistent Atrial Fibrillation in a Patient with a Left Pneumonectomy.

Pulmonary vein (PV) isolation (PVI) is the most important component of catheter ablation of atrial fibrillation (AF) and can be achieved by radiofrequency or cryoballoon ablation (CBA). The CBA system has shown excellent efficacy and safety in a number of clinical trials and is independent of the PV anatomy. However, pneumonectomy can significantly alter the anatomy posing a challenge to CBA.

Body Piercing with a Metallic Tongue Stud Resulting in Ineffective Implantable Cardioverter-defibrillator Shocks: "Heart to Mouth".

Left ventricular assist devices (LVADs) provide circulatory support to patients with severe left ventricular systolic dysfunction. Many such patients have a pre-existing implantable cardioverter-defibrillator (ICD) at the time of their LVAD surgery. LVAD implantation can alter the ICD lead parameters, including R-wave sensing, right ventricular capture threshold, and impedance.

Ventricular Fibrillation Cardiopulmonary Arrest Following Micra™ Leadless Pacemaker Implantation.

Leadless cardiac pacemakers such as the Micra™ transcatheter leadless pacing system (Medtronic, Minneapolis, MN, USA) are an alternative to traditional transvenous pacemakers. Implantation of leadless pacemakers, albeit safe, may be associated with complications, including cardiac tamponade; high capture thresholds; and, rarely, ventricular arrhythmias. We report a case of ventricular fibrillation arrest following the implantation of a Micra™ leadless pacemaker.

Azygous Vein Coil Implantation in Left Ventricular Assist Device Patients: A Hands-on Approach.

Recently, there have been reports of left ventricular assist device (LVAD) patients presenting with multiple ineffective implantable cardioverter-defibrillator (ICD) shocks. In such patients, the placement of an azygous vein coil by providing an alternative anteroposterior trajectory of the electrical shock vector can enable successful defibrillation. This review discusses a hands-on approach to azygous vein coil implantation.

Successful implantation of a left ventricular lead in an anomalous coronary sinus.

We describe the case of a 56-year-old man who was referred for CRT implantation and found to have anomalous CS. Catheterization of the CS initially failed due to this anomaly. However, a single large posterior-lateral branch with diminutive CS in the atrioventricular groove allowed for successful implantation of the LV lead.

"Retained wire femoral lead removal and fibroplasty" for obtaining venous access in patients with refractory venous obstruction.

Background: Patients with wire and catheter refractory venous occlusion are traditionally referred for pectoral transvenous lead extraction (TLE) to obtain venous access. TLE causes 1-2 mm circumferential mechanical or laser destruction of tissue surrounding the lead(s). This not only exposes the patient to the risk of major complications but also can damage nontargeted leads.

The combination of coronary sinus ostial atresia/abnormalities and a small persistent left superior vena cava-Opportunity for left ventricular lead implantation and unrecognized source of thromboembolic stroke.

Background: Coronary sinus (CS) ostial atresia/abnormalities prevent access to the CS from the right atrium (RA) for left ventricular (LV) lead implantation. Some patients with CS ostial abnormalities also have a small persistent left superior vena cava (sPLSVC).

Objective: The purpose of this study was to describe CS ostial abnormalities and sPLSVC as an opportunity for LV lead implantation and unrecognized source of stroke.

Interventional device implantation, Part I: Basic techniques to avoid complications: A hands-on approach.

Introduction: The essence of cardiac resynchronization therapy (CRT) is biventricular (BiV) pacing, which involves implanting pacing leads in both the right ventricle (RV) and left ventricle (LV). Unlike traditional RV pacing, many hurdles lie ahead of successful LV lead implantation.

Methods And Results: In this review, we first highlight the importance of optimizing the patient and the tools.

Challenging Implants Require Tools and Techniques Not Tips and Tricks.

The EP Clinics article "How to implant CRT devices in a busy clinical practice" describes the basics of the "interventional telescoping technique". This article focuses on specific circumstances where the tools and techniques are invaluable: (1) inability to locate the coronary sinus (CS), (2) inability to advance a catheter into the CS, (3) patients with CS atresia, (4) unstable CS access, (4) angulated target veins, (5) small and/or tortuous target veins, (6) target veins into which a wire cannot be advanced, (7) target veins with a drain pipe takeoff, (8) target veins close to the CS ostium.

Ranolazine in High-Risk Patients With Implanted Cardioverter-Defibrillators: The RAID Trial.

Background: Ventricular tachycardia (VT) and ventricular fibrillation (VF) remain a challenging problem in patients with implantable cardioverter-defibrillators (ICDs).

Objectives: This study aimed to determine whether ranolazine administration decreases the likelihood of VT, VF, or death in patients with an ICD.

Methods: This was double-blind, placebo-controlled clinical trial in which high-risk ICD patients with ischemic or nonischemic cardiomyopathy were randomized to 1,000 mg ranolazine twice a day or placebo.

Safety and Efficacy of Multipoint Pacing in Cardiac Resynchronization Therapy: The MultiPoint Pacing Trial.

Objectives: The MultiPoint Pacing (MPP) trial assessed the safety and efficacy of pacing 2 left ventricular sites with a quadripolar lead in patients with heart failure indicated for a CRT-D device.

Background: Cardiac resynchronization therapy nonresponse is a complex problem where stimulation of multiple left ventricular sites may be a solution.

Methods: Enrolled patients were indicated for a CRT-D system.

Venous System Interventions for Device Implantation.

Subclavian obstruction is common after lead implantation and the need to add or replace a lead is increasing. Subclavian venoplasty (SV) is a safe and effective option for venous occlusion. Peripheral venography overestimates the severity of the obstruction.

Rationale and design of a randomized trial to assess the safety and efficacy of MultiPoint Pacing (MPP) in cardiac resynchronization therapy: The MPP Trial.

Background: Although the majority of Class III congestive heart failure (HF) patients treated with cardiac resynchronization therapy (CRT) show a clinical benefit, up to 40% of patients do not respond to CRT. This paper reports the design of the MultiPoint Pacing (MPP) trial, a prospective, randomized, double-blind, controlled study to evaluate the safety and efficacy of CRT using MPP compared to standard biventricular (Bi-V) pacing.

Methods: A maximum of 506 patients with a standard CRT-D indication will be enrolled at up to 50 US centers.

Improvement in Clinical Outcomes With Biventricular Versus Right Ventricular Pacing: The BLOCK HF Study.

Background: Sustained right ventricular (RV) apical pacing may lead to deterioration in ventricular function and an increased risk of heart failure, especially in patients with pre-existing systolic dysfunction. The BLOCK HF (Biventricular Versus Right Ventricular Pacing in Heart Failure Patients With Atrioventricular Block) trial demonstrated that biventricular-paced patients had a reduced incidence of a composite endpoint of death, heart failure-related urgent care, and adverse left ventricular remodeling.

Objectives: In a pre-specified analysis, this study examined clinical outcomes, including clinical composite score, quality of life (QOL), and change in New York Heart Association (NYHA) functional classification.

Biventricular pacing for atrioventricular block and systolic dysfunction.

Background: Right ventricular pacing restores an adequate heart rate in patients with atrioventricular block, but high percentages of right ventricular apical pacing may promote left ventricular systolic dysfunction. We evaluated whether biventricular pacing might reduce mortality, morbidity, and adverse left ventricular remodeling in such patients.

Methods: We enrolled patients who had indications for pacing with atrioventricular block; New York Heart Association (NYHA) class I, II, or III heart failure; and a left ventricular ejection fraction of 50% or less.

Snare coupling of the pre-pectoral pacing lead delivery catheter to the femoral transseptal apparatus for endocardial cardiac resynchronization therapy : mid-term results.

Aims: Limitations imposed by the coronary sinus venous anatomy triggered the transseptal approach for endocardial LV lead placement. The alignment of the interatrial septum (IAS) and its neighborhood anatomy does not favor transseptal puncture from the pre-pectoral area. Locating and advancing a pre-pectoral LV lead delivery catheter (PDC) through an opening created in the IAS via femoral transseptal puncture (FTP) is time consuming and technically difficult.

Prolapsed double-canted bipolar left ventricular lead for pacing the left atrium via the coronary sinus: experience in 11 patients.

Aims: High thresholds and frequent lead dislodgement limit pacing the left atrium (LA) from the mid to distal coronary sinus (CS). The aim of this report is to describe a method for and the results of prolapsing a double-canted bipolar lead into the mid-to-distal CS to eliminate lead dislodgement and improve pacing thresholds.

Methods And Results: After CS access the 9 Fr.

Subclavian venoplasty by the implanting physicians in 373 patients over 11 years.

Background: The need to add a lead(s) despite subclavian/innominate obstruction is increasing. Subclavian venoplasty may be a good alternative to the commonly employed options; however, there are few reports in the literature, and all are by interventional radiologists.

Objective: To describe the procedural details, results and safety of venoplasty by implanting physicians in a large group of consecutive patients.

Excimer laser to open refractory subclavian occlusion in 12 consecutive patients.

Background: Ideally, new leads are placed via the axillary/cephalic vein on the same side as the initial implant; however, 3.6% to 9% of patients have chronic total subclavian/innominate occlusion. In most cases, a wire can be manipulated across the occlusion and venoplasty safely performed.

Goose neck snare for LV lead placement in difficult venous anatomy.

Venous anatomy frequently impairs placement of the left ventricular (LV) lead. In some cases, the wire will not advance into the vein and in others wire position is lost as the lead is advanced. This article describes how a commonly available goose neck snare is used to gain access to the distal end of the wire as it re-enters the coronary sinus retrograde via collaterals through an adjacent vein.

How to use balloons as anchors to facilitate cannulation of the coronary sinus left ventricular lead placement and to regain lost coronary sinus or target vein access.

Coronary venous anatomy can make successful implantation of a cardiac resynchronization therapy device difficult or impossible. Venogram and coronary balloons can be used as anchors to facilitate initial coronary sinus (CS) cannulation and left ventricular lead placement and to recover lost CS and target vein access.

Irrigated radiofrequency catheter ablation guided by electroanatomic mapping for recurrent ventricular tachycardia after myocardial infarction: the multicenter thermocool ventricular tachycardia ablation trial.

Background: Recurrent ventricular tachycardia (VT) is an important cause of mortality and morbidity late after myocardial infarction. With frequent use of implantable cardioverter-defibrillators, these VTs are often poorly defined and not tolerated for mapping, factors previously viewed as relative contraindications to ablation. This observational multicenter study assessed the outcome of VT ablation with a saline-irrigated catheter combined with an electroanatomic mapping system.

Focused force coronary venoplasty to eliminate a refractory stenosis preventing LV lead placement in two patients.

This report describes two patients who underwent a second attempt at cardiac resynchronization therapy (CRT) in the setting of a severe stenosis in the lateral coronary vein that prevented passage of a left ventricular lead. Both stenoses were unresponsive to standard noncompliant balloon dilatation but were successfully treated with the addition of a second stiff angioplasty wire beside the noncompliant balloon. Venoplasty with the addition of a side wire beside the balloon should be considered for resistant coronary vein stenosis encountered during CRT device implantation.