Left ventricular lead misplacement discovered a decade after cardiac resynchronization therapy-defibrillator implantation: a case report.

Introduction: Satisfactory left ventricular (LV) lead placement into the coronary sinus (CS) can be achieved in the majority of patients but there are still instances of acute failure most often due to anatomical differences, for example due to tortuous CS anatomy. Chronic LV lead misplacement and its delayed discovery is not a common scenario. It is unclear if chronic dual right ventricular pacing can hasten the progression of heart failure. Case presentation: A 73-year-old lady presented to our cardiac centre with severe heart failure. She had non-ischaemic dilated cardiomyopathy with underlying left bundle branch block and a cardiac resynchronization therapy-defibrillator device in situ for the past decade. She also had a chronic pericardial effusion of unknown aetiology. Whilst the patient was being treated for acute heart failure, it was noted on patient telemetry that the QRS morphology for supposed bi-ventricular pacing was unusual. This led to a lateral chest radiograph and a CS venogram to be performed, both of which confirmed that the LV lead was in fact not in the CS. Plans were made to place a new LV lead but unfortunately the patient continued to clinically deteriorate despite maximal treatment and died before this could be performed. Discussion: It is only with thorough review of the electrocardiographic data and chest radiography that led to the discovery of chronic LV lead misplacement. This case illustrates the importance of expert review of radiographic imaging and electrocardiographic data in patients with implanted cardiac devices

Innovative Cardiac Resynchronization: Deployable Lead as an Anchor to Facilitate Guidewire Advancement.

An acutely angulated coronary sinus ostium coupled with a dilated right atrium presents technical challenges for cardiac resynchronization therapy (CRT) implantation. Innovative use of a deployable left ventricle lead as an anchor to support guidewire navigation within the cardiac venous system permits optimal CRT deployment. (Level of Difficulty: Advanced.)

Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation.

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most frequent type of cardiac ablation procedure performed. Although generally safe, collateral injury to surrounding structures, particularly the esophagus, remains a concern. Cooling or warming the esophagus to counteract the heat from RF ablation, or the cold from cryoablation, is a method that is used to reduce thermal esophageal injury, and there are increasing data to support this approach. This protocol describes the use of a commercially available esophageal temperature management device to cool or warm the esophagus to reduce esophageal injury during left atrial ablation. The temperature management device is powered by standard water-blanket heat exchangers, and is shaped like a standard orogastric tube placed for gastric suctioning and decompression. Water circulates through the device in a closed-loop circuit, transferring heat across the silicone walls of the device, through the esophageal wall. Placement of the device is analogous to the placement of a typical orogastric tube, and temperature is adjusted via the external heat-exchanger console

Preventing esophageal complications from atrial fibrillation ablation: A review.

Atrioesophageal fistula is a life-threatening complication of ablation treatment for atrial fibrillation. Methods to reduce the risk of esophageal injury have evolved over the last decade, and diagnosis of this complication remains difficult and therefore challenging to treat in a timely manner. Delayed diagnosis leads to treatment occurring in the context of a critically ill patient, contributing to the poor prognosis associated with this complication. The associated mortality risk can be as high as 70%. Recent important advances in preventative techniques are explored in this review. Preventative techniques used in current clinical practice are discussed, which include high-power short-duration ablation, esophageal temperature probe monitoring, cryotherapy and laser balloon technologies, and use of proton pump inhibitors. A lack of randomized clinical evidence for the effectiveness of these practical methods are found. Alternative methods of esophageal protection has emerged in recent years, including mechanical deviation of the esophagus and esophageal temperature control (esophageal cooling). Although these are fairly recent methods, we discuss the available evidence to date. Mechanical deviation of the esophagus is due to undergo its first randomized study. Recent randomized study on esophageal cooling has shown promise of its effectiveness in preventing thermal injuries. Lastly, novel ablation technology that may be the future of esophageal protection, pulsed field ablation, is discussed. The findings of this review suggest that more robust clinical evidence for esophageal protection methods is warranted to improve the safety of atrial fibrillation ablation

Transvenous lead extraction: Experience of the Tandem approach.

BACKGROUND: Transvenous lead extraction (TLE) is important in the management of cardiac implantable electronic devices but carries risk. TLE is most commonly completed from the superior access, often with 'bail-out' support via the femoral approach. Superior and inferior access may be used in tandem, which has been proposed as an advance in safety and efficacy. AIM: To evaluate the safety and efficacy of the Tandem approach. METHOD: The 'Tandem' procedure entailed grasping of the targeted lead in the right atrium to provide countertraction as a rotational dissecting sheath was advanced over the lead from the subclavian access. Consecutive 'Tandem' procedures performed by a single operator between December 2020 - March 2023 in a single large-volume TLE centre were included and compared with the conventional superior approach (control) using 1:1 propensity score matching; patients were statistically matched for demographics. RESULTS: The Tandem in comparison to the conventional approach extracted leads of much greater dwell time (148.9±79 vs 108.6±77 months, p<0.01) in a shorter procedure duration (96±36 vs 127±67 minutes, p<0.01) but requiring more fluoroscopy (16.4±10.9 vs 10.8±14.9 minutes, p<0.01). The Tandem and control groups had similar clinical (100% vs 94.7%, p=0.07) and complete (94.8% vs 92.8%, p=0.42) success, with comparable minor (4% vs 6.7%, p=0.72) and major (0% vs 4%, p=0.25) complications; procedural (0% vs 1.3%, p=1) and 30-day (1.3% vs 4%, p=0.62) mortality were also similar. CONCLUSION: The Tandem procedure is as safe and effective as the conventional TLE. It can be applied to leads of a long dwell time with a potentially shorter procedure duration