Transseptal Delivery of a Leadless Left Ventricular Endocardial Pacing Electrode

^aDivision of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
^bDepartment of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom

↵∗Address for correspondence:
Dr. Benjamin J. Sieniewicz, Department of Imaging Sciences and Biomedical Engineering, 4th Floor, North Wing, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH, UK.

Key Words

A 79-year-old man with ischemic cardiomyopathy, left ventricular ejection fraction of 25%, an existing dual-chamber pacemaker (for complete heart blockage with >85% ventricular pacing), a broad QRS complex, and symptomatic heart failure was referred to our institution for cardiac resynchronization therapy. Prior attempts at cardiac resynchronization therapy at his referring hospital failed due to subclavian venous obstruction. He was deemed suitable for a wireless, left ventricular, endocardial pacing system (WiSE-CRT System, EBR Systems, Sunnyvale, California) (Figure 1). Assessment revealed that femoral arterial access would not be possible due to near total bilateral femoral arterial occlusion. The options of a direct aortic or a trans-septal approach were discussed at a multidisciplinary team meeting, and the decision was made to attempt trans-septal WiCS-LV implantation.

Figure 1

WiCS-LV Leadless Endocardial Pacing System

The ultrasound array is placed in the intercostal space, whereas the pacing electrode is implanted on the LV endocardial surface. LV = left ventricle; WiCS-LV = wireless cardiac stimulation of the left ventricle. Kindly reproduced with the permission of EBR Systems.

The patient was anesthetized, and transesophageal echocardiography (TEE) confirmed the absence of left atrial appendage thrombus. Right femoral venous access permitted a transseptal puncture with an 8 French Fast-cath transseptal guiding introducer Swartz SL1 (St. Jude Medical, Inc., St. Paul, Minnesota) using a Baylis NRG Transseptal Needle (Baylis Medical Company, Inc., Montreal, Canada) under TEE guidance (Figures 2A and 2B, Online Video 1). After full heparinization, the sheath size was increased using a 12 French Transseptal Mullins introducer sheath (Medtronic, Minneapolis, Minnesota) and positioned across the mitral valve, facilitating access to the lateral LV endocardial wall (Figure 3). The WiCS-LV delivery catheter was used to deploy the leadless pacing electrode in a favorable basolateral position (Figures 2C and 2D). This resulted in excellent electrical resychronization (Figure 4). The patient was discharged without complication.

Figure 2

Multipanel Views of the Transseptal Deployment of a WiCS-LV Pacing Electrode

The atrial septum is identified (A) before a puncture is made and crossed with a guidewire (B) (Online Video 1). The WiCS-LV delivery catheter can then be passed across the septum, allowing the leadless pacing electrode to be deployed in the lateral wall (C). The device is detached from the delivery mechanism, and the catheter is withdrawn (D). Abbreviation as in Figure 1.

Online Video 1

WiCS-LV electrode delivery

The WiCS-LV leadless pacing electrode was advanced down the delivery catheter

Figure 3

WiCS-LV Delivery Catheter Across the Septum

The WiCS-LV delivery catheter (blue arrow) was advanced across the septum and through the mitral valve. Abbreviation as in Figure 1.

Figure 4

Pre- and Post-ECG

A 12-lead ECG is shown pre-procedure (left) and post-procedure (right), confirming good electrical resynchronization with left ventricle endocardial cardiac resynchronization therapy. ECG = electrocardiogram.

This case demonstrates the first delivery of the WiCS-LV electrode into the LV endocardium using a trans-septal approach. This method mitigates the need for arterial access and closure devices, allowing implantation in patients with unfavorable arterial access and may reduce potential bleeding and access site issues, the most commonly encountered complication with this procedure. Transseptal implantation may allow more widespread use of this novel technology.

Footnotes

Dr. Gould is supported by a St. Jude Medical fellowship fund. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All 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 JACC: Clinical Electrophysiology author instructions page.