pre-procedural preparation and crt implantation tips and tricks

Pre-Procedural Preparation

and CRT Implantation

Tips and Tricks

THRS CIED PHYSICIAN TRAINING COURSE

Part III: CRT

19, Jun, 2016

Yung-Lung, Chen M.D.

Outlines

Pre-Procedural Preparation

CRT Implantation Tips and

Tricks

Outlines

Pre-Procedural Preparation

CRT Implantation Tips and

Tricks

Pre-Procedure preparation

Pre-Procedure preparation

Baseline clinical data

Image techniques

Electrical assessment (resting ECG)

Pre-implantation medical management

Baseline clinical data

Optimal medical management stable for at least 3 months before implant

Routine laboratory/biomarker

evaluation BNP/NT-proBNP

Growth differentiation factor-15; amino-terminal propeptide type III procollagen

Functional assessment

6 minutes hall walk test

CPET/ peak O2 consumption

Baseline clinical data

Quality of life measurements

The Minnesota Living with HF questionnaire

Determination of heart failure

aetiology/coronary angiography

Comorbidities/life expectancy

the Seattle heart failure model (SHFM)

Charlson comorbidity index

Non-ambulatory New York Heart

Association class IV

inotropic support/ beta-blocker intolerance

bail-out / last resort therapy

Image techniques

Basic anatomical and functional measures

Dyssynchrony evaluation by imaging/

echocardiography

Cardiac CTA and cardiac MRI

Cardiac CTA and cardiac MRI to define coronary

venous anatomy

Ventricular function and tissue characteristics

CTA: computed tomography angiography

MRI: magnetic resonance imaging

Electrical assessment:

resting ECG

P-wave and atrial rhythm

PR interval

QRS complex duration and morphology

ECG criteria for LBBB revisited

QT interval

Premature ventricular contractions

Additional electrophysiological

measurements (electroanatomic mapping)

Pre-implantation medical

management

Antithrombotics

bridging heparin abandoned

(12-20% pocket haepatoma)

low to moderate thromboembolic risk

(biologic valve, Afib. with CHADS2 score < 4,

no history of thromboembolic event)

PT INR 1.5-2.5 x or stop for 3-5 days VKA;

NOACs stop 2-3 days

Re-on the secondary day

aspirin or dual antiplatelet 2-4x risk (3.9-7.2% v.s. 1.6%)

primary prevention, low risk, high risk

KCGMH data

Can J Cardiol. 2013 Sep;29(9):1110-7.

Pre-implantation medical

management

Antibiotics

Multicenter registry(6319pts/44H):0.68%/1yr

Risks: temporary pacing or other procedures, early reintervention and without antibiotic prophylaxis.

DBRT: 3.28%0.63% 1gm cefazolin iv.

Peri-OP antibiotics: cefazolin 1 hr before

vancomycin 2 hr before

Contrast induced nephrotoxicity

Hydration; acetylcysteineDBRT: Double blind-randomized trial

Outlines

Pre-Procedural Preparation

CRT Implantation Tips and

Tricks

Steps in CRT Implantation

Pre-implant preparation

CXR / Implant setup and tools

PPM wound prepare

Venography/Venous access

RV lead position

Cannulate coronary sinus

Perform CS venograms

Select target vein and leads

Place leads

Measure final parameters

Remove implant tools

Program CRT devices

Steps in CRT Implantation

CXR / Implant setup and tools

PPM wound prepare

Venography/Venous access

RV lead position

Cannulate coronary sinus

Perform CS venograms

Select target vein and leads

Place leads

Measure final electricals

Remove implant tools

CXR

CS Cannulation Catheters

Metronic

Steps in CRT Implantation

CXR / Implant setup and tools

PPM wound prepare

Venography/Venous access

RV lead position

Cannulate coronary sinus

Perform CS venograms

Select target vein and leads

Place leads

Measure final electricals

Remove implant tools

PPM wound area prepare

Steps in CRT Implantation

CXR / Implant setup and tools

PPM wound prepare

Venography/Venous access

RV lead position

Cannulate coronary sinus

Perform CS venograms

Select target vein and leads

Place leads

Measure final electricals

Remove implant tools

Venography

Venous access

Preferably start from left site

Preferably use 3 or 2 different access

points to reduce friction

o Always use separate access point for

LV lead

Cut-down or Puncture

Cut-down or Puncture

Steps in CRT Implantation

CXR / Implant setup and tools

PPM wound prepare

Venography/Venous access

Order of lead placement/RV lead position

Cannulate coronary sinus

Perform CS venograms

Select target vein and leads

Place leads

Measure final electricals

Remove implant tools

Order of lead placement

PRO CON

LV Lead

Placed

FIRST

1. No interference from other

leads being in the way

2. May save time & money

1. Other means

of back-up

pacing

RV Lead

Placed

FIRST

1. Back up pacing

2. Idea of RA dimension &

general cardiac anatomy

1. May get in way

of LV sheath

Position of RV lead

Optimal site still not determined

Mid septal or RVOT preferred by some

However DFT may be higher

Steps in CRT Implantation

CXR / Implant setup and tools

PPM wound prepare

Venography/Venous access

RV lead position

Cannulate coronary sinus

Perform CS venograms

Select target vein and leads

Place leads

Measure final electricals

Remove implant tools

Burkhardt, J. D. et al. Circulation 2007;115:2208-2220

Right atrial anatomy and

relationship to coronary sinus

Cannulating Coronary OS

Key points in the anatomy of the

CS ostium (OS)

o The OS is in the posteroseptal region

of the RA & may be obstructed by

Thebesian valve

o The OS is not on the floor of the RA,

but up 1 to 2 cm

o As the RA dilates the OS may be

more posterior and ~1 cm higher

Effect of CCWR rotation

First moves to the left

Then, moves downwards

Start here

From: Clinical Cardiac Pacing, Defibrillation and CRT by Ellenbogen

Effect of CCWR rotation

Staring too low

From: Clinical Cardiac Pacing, Defibrillation and CRT by Ellenbogen

Cannulating Coronary OS:

From below

Cannulating Coronary OS:

From above

Cannulation of CS OS

Materials used:

Outer Guide Catheter

Guidewire

EP catheter

Coronary catheter (JR, AL)

Inner sheath (Cannulators)

Cannulating Coronary OS:

Our Way

Cannulating Coronary OS:

Our Way

Cannulating Coronary Os:

EP approach

Cannulation_Method3-EP_Approach.wmv

Cannulation of CS OS

IEGM to confirm position

A / V > 1

Atrial signal at the end of the P-wave

Tips to advance sheath in CS

A guidewire can

be used to guide

the sheet

First advance the

EP catheter or

Cannulator (inner

sheath) over the

guide

Advance the outer

sheath Direct

From: Clinical Cardiac Pacing, Defibrillation and CRT by Ellenbogen

Steps in CRT Implantation

CXR / Implant setup and tools

PPM wound prepare

Venography/Venous access

RV lead position

Cannulate coronary sinus

Perform CS venograms

Select target vein and leads

Place leads

Measure final electricals

Remove implant tools

Coronary venogram

• Flush balloon catheter prior to

use.

• Test the balloon in a basin of

saline prior to insertion to

determine the volume of air

required for inflation, and to

insure that no air embolus will

be introduced.

• Always use the manufacture's

syringe to inflate the balloon

Performing venogram

• Inject contrast in order to verify

location, thereafter inflate the balloon.

• Do not use to much pressure.

• See to that the catheter tip is not blocked

against the vein wall.

• Avoid inflating the balloon where it

possible could damage the vein

• insure that a dissection has not taken

place prior to balloon inflation

• Give an initial gentle puff of contrast

before inflating the balloon to verify

proper positioning within the CS,

thus preventing dissection or staining.

Coronary venography

Coronary vein

LV lead position: lessons

from MADIT-CRT

Circulation March 22, 2011

Conclusion: LV leads positioned in the apical region were

associated with an unfavorable outcome, suggesting that this

lead location should be avoided in cardiac resynchronization

therapy

Selecting target vein

size

angulation

tortuosity

Occlusive Coronary

Venogram

Always 3 views: AP-LAO-RAO

AP, RAO and LAO show different onset of the target vein

From: Clinical Cardiac Pacing, Defibrillation and CRT by Ellenbogen

RAOLAO

Quadripolar vs Bipolar leads

LV leads-SJM

Lead Lead

body size

Polarity

QuickFlex

1258T

4.3Fr Bipolar

Quartet

1458T

4.7 Fr Quadripol

ar

LV Lead-Medtronic

Leads Lead Body Size Polarity

Attain® OTW

Model 4193

4 Fr (1.3 mm) Unipolar

Attain OTW

Model 4194

6.2 Fr (2.0 mm) True

bipolar

Attain Starfix

Model 4195

5 Fr (1.7 mm) Unipolar

Attain Ability

Model 4196

4 Fr (1.3 mm) Bipolar

(dual

electrode)

Attain Performa 5.3Fr Quadripola

r

Steps in CRT Implantation

CXR / Implant setup and tools

PPM wound prepare

Venography/Venous access

RV lead position

Cannulate coronary sinus

Perform CS venograms

Select target vein and leads

Place leads

Measure final electricals

Remove implant tools

Handling options to suit your technique

Over-the-wire or stylet-driven design allows use of either a

stylet or guidewire

Guidewire can be either front-loaded or back-loaded

You need a separate 0.014” guidewire (not in the package)

Guidewire or stylet

Lead position

Best site to pace LV

Anatomical – lateral vein

Fluroscopy – RV and LV lead tip as far apart

anatomically as possible

Electrogram – LV egm at late in QRS as possible, RV

and LV electrogram as far apart as possible

Hemodynamic – best dP/dt, pulse pressure

ECG – QRS narrowing during pacing

Latest area of mechanical activation as determined by

imaging tools – eg echo, MRI,

Best site to pace LV

Anatomical – lateral vein

Fluroscopy – RV and LV lead tip as far apart

anatomically as possible

Electrogram – LV egm at late in QRS as possible, RV

and LV electrogram as far apart as possible

Hemodynamic – best dP/dt, pulse pressure

ECG – QRS narrowing during pacing

Latest area of mechanical activation as determined by

imaging tools – eg echo, MRI,

Final positioning

RAO LAO

Lead Delivery

Electrical Measurements

o Threshold

o Sensing amplitude / separation Goal of at least 100 msec between RV and LV senses.

o Nervus Phrenicus stimulation

Best site to pace LV

Anatomical – lateral vein

Fluroscopy – RV and LV lead tip as far apart

anatomically as possible

Electrogram – LV egm at late in QRS as possible, RV

and LV electrogram as far apart as possible

Hemodynamic – best dP/dt, pulse pressure

ECG – QRS narrowing during pacing

Latest area of mechanical activation as determined by

imaging tools – eg echo, MRI,

LV electrical lead position

SR, LBBB, QRS: 189 ms

LAO

50°

His

Bundle

RAO

30°

Earliest Ventricular

Activation

LAO

90°

Latest Ventricular

Activated Region

Sites to avoid

Anterior (GCV) pacing

Apical LV lead position

Phrenic nerve stimulation

Scar areas

Steps in CRT Implantation

CXR / Implant setup and tools

PPM wound prepare

Venography/Venous access

RV lead position

Cannulate coronary sinus

Perform CS venograms

Select target vein and leads

Place leads

Measure final parameters

Remove implant tools

Electrical Measurements

Electrical Measurements

o Threshold (< 3 V)

o Sensing amplitude / separation

o Impedence (mid-range of

manufacturer’s specifications)

o Nervus Phrenicus stimulation (10 V)

Real Case (1)

Real Case (2)

Real Case (3)

Real Case (4)

Real Case (5)

Steps in CRT Implantation

CXR / Implant setup and tools

PPM wound prepare

Venography/Venous access

RV lead position

Cannulate coronary sinus

Perform CS venograms

Select target vein and leads

Place leads

Measure final parameters

Remove implant tools

Removing Implant Tools

Be sure the stylet or guidewire is in

place before removing the sheath.

Be sure that the S-shape of the

lead is not retained by the stylet.

Use continuous Fluo.

Re-test thershold, NP stimulation

after removing tools

Removing Implant Tools

76

Snap lead into lead

channel of slitter

77

Slitting

78

Incorrect Slitting

79

Correct Slitting

80

Incorrect Slitting

Fixating the leads

Connect CRT devices

CRT-PCRT-D

IS4 & DF4 Connector Pin Differences

Lead Connector dimensions are the same except for the pin

DF4-LLHH

IS4-LLLL

Pin is steps down to

a smaller diameter

Pin is larger

diameter & does

NOT step down

Thanks for your attention!!

Pre-Procedure preparation

Europace (2012) 14, 1236–1286

Pre-Procedure preparation

Europace (2012) 14, 1236–1286

Pre-Procedure preparation

Europace (2012) 14, 1236–1286

Methods of patient assessment

prior to CRT implant

Europace (2012) 14, 1236–1286

CRT implant recommendation

Europace (2012) 14, 1236–1286

CRT implant recommendation

Europace (2012) 14, 1236–1286