Author + information
- Received February 10, 2017
- Revision received April 5, 2017
- Accepted April 11, 2017
- Published online September 13, 2017.
- Benjamin J. Sieniewicz, MBChBa,b,∗ (, )
- Justin S. Gould, MBBSa,b,
- Helen M. Rimington, BSc, PhDa,b,
- Nicholas Ioannou, BA, MBBS, MAb and
- Christopher A. Rinaldi, MBBS, MDa,b
- 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.
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.
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.
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.
For a supplemental video and legend, please see the online version of this article.
Dr. Gould is supported by a St. Jude Medical fellowship fund. All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received February 10, 2017.
- Revision received April 5, 2017.
- Accepted April 11, 2017.
- 2017 American College of Cardiology Foundation