Limited venous access and lateral left ventricular scar are impediments to traditional cardiac resynchronization therapy. We present a case where placement of an implantable cardioverter-defibrillator from a femoral approach while using left bundle branch area pacing led to clinical improvement. (Level of Difficulty: Intermediate.

Dhakal, Bishnu

Magargee, Edward

Modi, Danesh

Movsowitz, Colin

Prenner, Stuart

Schaller, Robert

Jefferson Digital Commons

Thomas Jefferson University Jefferson Digital Commons Division of Cardiology Faculty Papers Division of Cardiology 3-1-2023 Left Bundle Branch Area Pacing From a Femoral Approach in a Patient Without Superior Access Bishnu Dhakal Stuart Prenner Edward Magargee Danesh Modi Colin Movsowitz See next page for additional authors Follow this and additional works at: https://jdc.jefferson.edu/cardiologyfp  Part of the Cardiology Commons Let us know how access to this document benefits you This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Division of Cardiology Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: JeffersonDigitalCommons@jefferson.edu. Authors Bishnu Dhakal, Stuart Prenner, Edward Magargee, Danesh Modi, Colin Movsowitz, and Robert Schaller CASE REPORTCLINICAL CASELeft Bundle Branch Area Pacing From aFemoral Approach in a Patient WithoutSuperior AccessBishnu P. Dhakal, MBBS,a Stuart B. Prenner, MD,b Edward R. Magargee, MD,c Danesh S. Modi, DO,cColin Movsowitz, MD,c Robert D. Schaller, DOaABSTRACTLimited venous access and lateral left ventricular scar are impediments to traditional cardiac resynchronization therapy.We present a case where placement of an implantable cardioverter-defibrillator from a femoral approach while using leftbundle branch area pacing led to clinical improvement. (Level of Difficulty: Intermediate.) (J Am Coll Cardiol Case Rep2023;9:101748) © 2023 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).HISTORY OF PRESENTATIONA 64-year-old man with a mixed cardiomyopathy, leftbundle branch block, ventricular tachycardia, andupper and lower deep vein thrombosis was admittedfor progressive heart failure.PAST MEDICAL HISTORYThe patient earlier underwent failed attempts toplace a biventricular implantable cardioverter-defibrillator (BiV ICD) from above and belowbecause of complete occlusion of the bilateralthoracic veins (Figure 1) and the inferior vena cava(Figure 2A), respectively. He previously underwentleft ventricular (LV) pseudoaneurysm repair, with arecent left heart catheterization showing stable cor-onary disease. He was deemed a poor surgicalcandidate for a completely epicardial pacing systemand was unable to be discharged from the hospitalbecause of his tenuous clinical status. The patientdeveloped complete heart block and underwentLEARNING OBJECTIVES To identify a patient who would benefit fromconduction system pacing. To appreciate the unique challenges andsolutions of performing conduction systempacing from a femoral approach.ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2023.101748From the aSection of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University ofPennsylvania, Philadelphia, Pennsylvania, USA; bDepartment of Medicine, Cardiovascular Division, Perelman School of Medicine,University of Pennsylvania, Philadelphia, Pennsylvania, USA; and the cCardiology Consultants of Philadelphia, Einstein MedicalCenter Montgomery, East Norriton, Pennsylvania, USA.The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,visit the Author Center.Manuscript received November 4, 2022; revised manuscript received December 19, 2022, accepted January 5, 2023.J A C C : C A S E R E P O R T S V O L . 9 , 2 0 2 3ª 2 0 2 3 T H E A U T H O R S . P U B L I S H E D B Y E L S E V I E R O N B E H A L F O F T H E AM E R I C A NC O L L E G E O F C A R D I O L O G Y F OU N D A T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E RT H E C C B Y - N C - N D L I C E N S E ( h t t p : / / c r e a t i v e c o mm o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / ) .venoplasty of the inferior vena cava(Figures 2B to 2D) followed by implantation ofa leadless right ventricular (RV) pacemaker(Micra AV, Medtronic), further worsening hisheart failure and requiring initiation ofintravenous milrinone.DIFFERENTIAL DIAGNOSISThe clinical history, presentation, and timingof his symptoms suggest that his heart failurewas attributable to multiple etiologies. The differen-tial diagnosis includes ischemic cardiomyopathy,ventricular dyssynchrony caused by RV pacing, lackof stable atrioventricular synchrony caused by aleadless permanent pacemaker, and progression ofnonischemic cardiomyopathy from other causes.INVESTIGATIONSEchocardiography showed an LV ejection fraction of19% with severe functional mitral regurgitation.Computed tomography showed a partially repairedand calcified lateral LV pseudoaneurysm measuring6.0  2.3 cm (Figure 3). The patient’s creatinine levelhad increased to 3.1 mg/dL.MANAGEMENTThe patient was referred for implantation of afemoral BiV ICD using left bundle branch area pacing(LBBAP). He was placed under general anesthesia,and his groin was prepped to the level of the umbi-licus. Right common femoral venous access was ob-tained from the inguinal crease, and 2 wires wereplaced (Figure 4A). A 4-cm horizontal incision wasmade 1.5 cm above the inguinal crease, and the wireswere grasped and pulled through the incision(Figure 4B). A 9-F sheath was inserted followed by acoronary sinus (CS) catheter (Attain CommandExtended Hook Extra Large, Medtronic) that wasguided to the RV (Figure 5A). A 130 inner catheter(Attain Select II, Medtronic) was placed within theouter sheath anterior and inferior to the His bundleand positioned perpendicular to the ventricularseptum (Figures 5B and 5C). A pacing lead (3830SelectSecure, 74 cm, Medtronic) was inserted, and togain more usable lead length, the suture sleeve wasremoved, and 2 cm of the proximal end of the innersheath was cut (Figures 4C and 4D). The lead wasscrewed into the RV septum until fixation beats wereappreciated (Figures 5D to 5G). The unipolar QRScomplex morphology showed a qR pattern in V1 witha width of 222 ms and an LV activation time of 105 msin V6 (Figure 6), a pacing threshold of 0.75 V at0.5 ms, and sensing of 12 mV. In bipolar configura-tion, anodal capture resulted in a QRS interval of196 ms with an anodal threshold of 2.5 V at 0.5 msand a cathodal threshold of 0.75 V at 0.4 ms. Thesheaths were split (Figure 5H), and a new suturesleeve was fixated. The second access point was“double wired,” and a CS cannulation catheter(Worley Jumbo, Merit Medical) was placed. A dual-coil ICD lead (6947 Quattro MRI, 65 cm, Medtronic)was inserted as close to the apex as possible and ul-timately secured to the mid septum (Figure 5I) withexcellent parameters. A 7-F sheath was placed overthe final wire, and an atrial lead (5076 CapsureFixNovus MRI, 85 cm, Medtronic) was secured to theright atrial appendage with excellent parameters(Figure 5I). A second anchoring suture sleeve wasplaced on the LBBAP and right atrial leads in a “U-loop” configuration (the RV lead did not have suffi-cient length) and was directed toward the pocket toprovide further stability (Figure 7A).A subcutaneous pocket was created (Figure 7B),and the generator was placed superior to the suturesleeves and secured with a silk tie (Figure 7C and D).The pocket was irrigated, and an absorbableantibiotic envelope (TYRX, Medtronic) was placedbefore closure with 2 layers of absorbable suturesFIGURE 1 Composite Image of Peripheral Contrast Venography Showing BilateralOcclusionsABBR EV I A T I ON SAND ACRONYMSBiV = biventricularCS = coronary sinusICD = implantablecardioverter-defibrillatorLBBAP = left bundle brancharea pacingLV = left ventricularRV = right ventricleDhakal et al J A C C : C A S E R E P O R T S , V O L . 9 , 2 0 2 3LBBAP via Femoral Approach M A R C H 1 , 2 0 2 3 : 1 0 1 7 4 82and medical adhesive (DERMABOND, Ethibond)(Figure 7E). Upon initiation of cardiac resynchroniza-tion therapy (Figure 6), the systolic blood pressureimmediately increased by 20 mm Hg, and milrinonewas able to be decreased on postoperative day 3 withimprovement of the patient’s creatinine level from3.1 mg/dL to 1.7 mg/dL at discharge.DISCUSSIONLBBAP is an emerging alternative to traditional car-diac resynchronization therapy,1 with this case thefirst to our knowledge from a femoral approach.Femoral cardiac implantable electronic device im-plantation has been previously described2,3 but hasbeen used sparingly because of surgical and leadlessoptions. Traditional CS leads from a femoral routehave also been described4; however, this strategy wasunappealing in our patient because of the presence ofa large lateral LV scar.The risk of lead dislodgement from a femoralapproach was shown to be high in 2 prior case se-ries.5,6 We left significant lead slack to reduce theFIGURE 2 Percutaneous Recanalization of the Inferior Vena Cava(A) Contrast venography shows complete occlusion of the inferior vena cava. (B) The occlusion has been crossed with a wire. (C, D) Successful venoplasty.FIGURE 3 Computed Tomography of the Chest Showing Left Ventricular MyocardialCalcificationNote the associated pseudoaneurysm measuring 6.0  2.3 cm (yellow arrow).J A C C : C A S E R E P O R T S , V O L . 9 , 2 0 2 3 Dhakal et alM A R C H 1 , 2 0 2 3 : 1 0 1 7 4 8 LBBAP via Femoral Approach3chance of dislodgement, including a “U-loop”anchoring suture above the inguinal crease to preventmovement. The defibrillation threshold was nottested because of the patient’s tenuous hemody-namics and is thus unknown. Programming with a“cold can” was used to optimize the shock vector, butthe effects of other configurations are not clear,including the use of an abdominal “hot can” with orwithout the use of a subcutaneous coil.7 Importantly,the patient’s height of 66 inches likely facilitated theuse of tools that might not be amenable to tallerpatients.FOLLOW-UPChest, abdomen, and pelvis x-ray films showed thedevice to be in a stable position (Figure 8). Unfortu-nately, the patient died suddenly at home 3 monthsafter the procedure with no interrogation or autopsydata available for review.CONCLUSIONSBiV ICD implantation with LBBAP lead placement isfeasible for patients who do not have upper extremityaccess.FUNDING SUPPORT AND AUTHOR DISCLOSURESThis work was supported by the Pennsylvania Steel CompanyElectrophysiology Research Fund. The funder played no role inconduct of the study, preparation of the manuscript, or decision tosubmit the publication. Dr Schaller has received speaking honorariafrom Medtronic. All other authors have reported that they have norelationships relevant to the contents of this paper to disclose.ADDRESS FOR CORRESPONDENCE: Dr Robert D.Schaller, Hospital of the University of Pennsylvania–Pavilion, Department of Cardiac Electrophysiology,One Convention Avenue, Level 2–City Side, Phila-delphia, Pennsylvania 19104, USA. E-mail: robert.schaller@pennmedicine.upenn.edu.FIGURE 4 Femoral Surgical Procedure(A) Venous puncture within the inguinal crease followed by an incision 1 to 2 cm superior. (B) Wire is grasped (black arrow) and pulled through the pocket. (C) Leadtested through an outer coronary sinus and modified inner coronary sinus sheath. (D) Right ventricular delivery sheath is split and removed.Dhakal et al J A C C : C A S E R E P O R T S , V O L . 9 , 2 0 2 3LBBAP via Femoral Approach M A R C H 1 , 2 0 2 3 : 1 0 1 7 4 84FIGURE 5 Biventricular Implantable Cardioverter-Defibrillator Implantation From a Femoral Access Point Using Left Bundle BranchArea Pacing(A) A coronary sinus outer sheath is guided to the right ventricle (B) RAO and (C) LAO fluoroscopic angulations show the inner within the outercoronary sinus sheath positioned perpendicular to the septum. (D to G) The left bundle branch area pacing lead is screwed into the rightventricular septum. (H) The outer sheath is prepared to be slit after the inner sheath was removed. (I) Final biventricular implantablecardioverter-defibrillator system. AP ¼ anterior posterior; LAO ¼ left anterior oblique; RAO ¼ right anterior oblique.J A C C : C A S E R E P O R T S , V O L . 9 , 2 0 2 3 Dhakal et alM A R C H 1 , 2 0 2 3 : 1 0 1 7 4 8 LBBAP via Femoral Approach5FIGURE 6 A 12-lead electrocardiogram of various pacing configurations(Left) Baseline right ventricular pacing (RVP). (Middle) Left bundle branch area pacing threshold testing with loss of anodal capture (asterisk) and widening of the QRSinterval. (Right) The resultant QRS from fusion between LBBAP (40 ms early) and RVP.FIGURE 7 Lead stabilization and pocket creation(A) A second suture sleeve was placed in a “U-loop” fashion to reduce lead tension (black arrow). Note the that the implantable cardioverter-defibrillator lead was notlong enough to place a second suture. (B) The subcutaneous plane was identified (white arrow), and (C) the generator was placed. A nonabsorbable suture (blackarrow) secures the generator to the pocket floor. (D) The generator sits superior to the lead suture sleeves. (E) The pocket is closed with absorbable suture and medicaladhesive.Dhakal et al J A C C : C A S E R E P O R T S , V O L . 9 , 2 0 2 3LBBAP via Femoral Approach M A R C H 1 , 2 0 2 3 : 1 0 1 7 4 86RE F E RENCE S1. Sharma PS, Vijayaraman P. Conduction systempacing for cardiac resynchronisation. ArrhythmElectrophysiol Rev. 2021;10:51–58.2. Brandao L, Miranda R, Almeida S, et al. Cardiacresynchronization therapy: femoral approach. RevPort Cardiol. 2017;36:309.e1–309.e3.3. Pinski SL, Bredikis AJ. Defibrillator implantationvia the iliac vein. Pacing Clin Electrophysiol.2000;23:1315–1317.4. Chaggar PS, Skene C, Williams SG.The transfemoral approach for cardiacresynchronization therapy. Europace.2015;17:173.5. Ellestad MH, Caso R, Greenberg PS. Permanentpacemaker implantation using the femoral vein: apreliminary report. Pacing Clin Electrophysiol.1980;3:418–423.6. Mathur G, Stables RH, Heaven D, Ingram A,Sutton R. Permanent pacemaker implantation viathe femoral vein: an alternative in cases withcontraindications to the pectoral approach. Euro-pace. 2001;3:56–59.7. Yamanouchi Y, Mowrey KA, Niebauer MJ,Tchou PJ, Wilkoff BL. Additional lead improvesdefibrillation efficacy with an abdominal ‘hot can’electrode system. Circulation. 1997;96:4400–4407.KEY WORDS cardiac resynchronizationtherapy, femoral device, left bundle brancharea pacing, left bundle branch block, venousocclusionFIGURE 8 Composite Chest, Abdominal, and Pelvic Radiograph Shows Final Lead and Generator PositionsJ A C C : C A S E R E P O R T S , V O L . 9 , 2 0 2 3 Dhakal et alM A R C H 1 , 2 0 2 3 : 1 0 1 7 4 8 LBBAP via Femoral Approach7

Left Bundle Branch Area Pacing From a Femoral Approach in a Patient Without Superior Access

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Left Bundle Branch Area Pacing From a Femoral Approach in a Patient Without Superior Access

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