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. We describe a method where the PDC is snare coupled to the femoral transseptal apparatus (FTA). When the FTA is advanced into the left atrium (LA) the coupled PDC follows.

Methods: The catheter of a 25-mm loop snare kit is replaced with the PDC (SelectSite®). The snare loop is positioned in the right common iliac vein from the pre-pectoral access. The PDC is coupled to the FTA by advancing the transseptal apparatus through the open snare loop. After conventional FTP, the FTA is withdrawn back into the right atrium (RA) over an extra support wire positioned in the LA. The PDC with open snare loop is pulled over the FTA up to the RA. The PDC is advanced to close the snare loop on the extra support wire immediately distal to the tip of the dilator close to the puncture site. The PDC is deflected to align with the FTA. The snare coupled catheters are gently advanced across the IAS into the LA. The PDC is released from the FTA by advancing the snare and opening the loop; the snare is then removed from the PDC. The PDC is deflected and advanced into the left ventricle (LV). After positioning the 4.1 Fr lumen less LV lead, the PDC is sliced and removed.

Results: The PDC snare coupled to the FTA was advanced into the LA in all five patients, however, access was lost during catheter manipulation in the one right-sided case. Endocardial LV lead was successfully positioned in all five patients.

Conclusion: Snare coupling the pre-pectoral SelectSite® catheter to the FTA is technically simple, reliable and a safe method for transseptal endocardial LV lead placement for left pre-pectoral implantation.