technical aspects of lead implantation for left ventricle

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1 - Head of Heart Rhythm Service of the Cardiovascular Clinical andSurgical Team of Prof. Dr. Sérgio Almeida de Oliveira in HospitalReal and Benemérita Sociedade Portuguesa de Beneficência, São Paulo2 - Titular professor of Surgery of the Medical Sciences School ofthe State University in Campinas-UNICAMP3 - Professor in charge of the Heart Surgery Department of theSurgery Service Medical Sciences School of the State University inCampinas-UNICAMP4 - Assistant Doctor Cardiovascular Clinical and Surgical Team ofProf. Dr. Sérgio Almeida de Oliveira in Hospital Real and BeneméritaSociedade Portuguesa de Beneficência, São Paulo5 - Doctor in charge of the Heart Stimulation Service of ClinicalCardiology of São Paulo, Itápolis – SP6 - Doctor of Heart Rhythm Service of the Cardiovascular Clinicaland Surgical Team of Prof. Dr. Sérgio Almeida de Oliveira in HospitalReal and Benemérita Sociedade Portuguesa de Beneficência, São Paulo.7 - Director and head of the Cardiovascular Clinical and SurgicalTeam of Prof. Dr. Sérgio Almeida de Oliveira in Hospital Real andBenemérita Sociedade Portuguesa de Beneficência, São Paulo.

Correspondence address:Av. Gregório Boggossian Sobrinho 60, condomínio Tamboré V,casa 53, Tamboré, Santana do Parnaiba-SP. CEP: 06543-385.E-mail: [email protected]

Fernando Sérgio Oliva de SOUZA1, Domingo Marcolino BRAILE2, Reinaldo Wilson VIEIRA3, Salomon OrdinolaROJAS4, Nicola Luciano MORTATI5, Alexandre Caputo RABELO6, Sérgio Almeida de OLIVEIRA7

Braz J Cardiovasc Surg 2005; 20(3): 301-309ORIGINAL ARTICLE

Article received in January, 2005Article accepted in June, 2005

RBCCV 44205-763

Aspectos técnicos do implante de eletrodo para estimulação ventricular esquerda através do seiocoronariano, com a utilização de anatomia radiológica e eletrograma intracavitário, na terapia deressincronização cardíaca

Technical aspects of lead implantation for leftventricle pacing through the coronary sinus, usinganatomic radiology and intracavitaryelectrography in the cardiac resynchronizationtherapy

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SOUZA, FSO ET AL - Technical aspects of lead implantation for leftventricle pacing through the coronary sinus, using anatomic radiologyand intracavitary electrography in the cardiac resynchronizationtherapy

Braz J Cardiovasc Surg 2005; 20(3): 301-309

AbstractObjective: To present the experience of 157 implantations

using a simplified technique for coronary sinuscatheterization, based on the atrial component of theintracavitary electrogram and radiological anatomy, showingthe success rate and total time of radioscopy use.

Method: From October 2001 to February 2005, 157biventricular pacemaker implantations were performed inpreviously selected patients, using radiological anatomy andobservation of the intracavitary electrogram, focusing on theatrial component. Here we show the success rate,complications and total time of radioscopy use.

Results: The implantation of the system employing leftventricular pacing via the coronary sinus was not possible in11 patients. Difficulties in cannulation of the coronary ostiumwere felt in 20 patients and difficulties of lead advancementthrough the coronary sinus existed in 39 patients. The meantime of radioscopy use was 18.27 ± 15.46 minutes.

Conclusion: The implantation technique, proposed by theauthor, using the atrial component morphology of theintracavitary electrogram and radiological anatomy provedto be safe and effective for the cannulation of the coronarysinus ostium requiring shorter radioscopy times.

Descriptors: Heart failure, congestive. Cardiomyopathy,congestive. Cardiac pacing, artificial.

ResumoObjetivo: Apresentar a experiência de 157 implantes

utilizando uma técnica simplificada para cateterização doseio coronariano, baseada no eletrograma intracavitário eanatomia radiológica, demonstrando o porcentual de sucessoe tempo total de utilização de radioscopia.

Método: De outubro de 2001 a fevereiro de 2005, foramrealizados 157 implantes de marcapasso biventricular empacientes previamente selecionados, utilizando-se anatomiaradiológica e observação de eletrograma intracavitário,demonstrando a taxa de sucesso, complicações e tempo totalde utilização de radioscopia.

Resultados: O implante do sistema, utilizando-se aestimulação do ventrículo esquerdo via seio coronariano, nãofoi possível em onze procedimentos. Em 20 pacientes foramobservadas dificuldades na canulação do óstio coronário e em39 pacientes observou-se dificuldade de progressão do eletrodoatravés do seio coronário. O tempo médio de utilização deradioscopia foi 18,27 ± 15,46 min.

Conclusão: A técnica de implante, proposta pelo autor,utilizando o eletrograma intracavitário e anatomiaradiológica, demonstrou ser segura e eficaz para canulaçãodo óstio do seio coronário, necessitando de reduzidos temposde radioscopia.

Descritores: Insuficiência cardíaca congestiva.Miocardiopatia congestiva. Estimulação cardíaca artificial.

INTRODUCTION

Recent studies have demonstrated that cardiacresynchronization through biventricular pacing is aimportant coadjuvant treatment in optimized medicinaltherapy of patients with refractory congestive heartfailure caused by chronic left ventricular dysfunctionand intraventricular conduction disorders, promotingan improvement in the heart function and the quality oflife [1-3].

The technique of left ventricular pacing can be performedboth epimyocardially by thoracotomy, or through theepicardium using the transvenous method. Although thelatter technique is the gold standard, the greatest limitationof this treatment is the catheterization and insertion of alead in the coronary sinus (CS) and its branches for leftventricle pacing [4].

The implantation of a specific electrode for left ventricularpacing is a relatively complex procedure, which involvesvariations in the anatomy of coronary veins, the quality of

the material utilized and the surgeon’s experience [5]. Theimpossibility of CS catheterization, variations in the anatomyof coronary venous system and diaphragmatic pacing arethe most common reasons for lead placement to beunsuccessful. Failure rates tend to decrease with thedevelopment of new electrodes and the surgeon’s experience[6-9].

With the good results presented by this coadjuvanttreatment, cardiac resynchronization therapy is becoming aroutine treatment for pre-selected patients. Due to thecomplexity of the procedure, the medical-scientificengineering professionals have been investing in theadaptation of materials to facilitate the implantationtechnique [7,10,11].

The objective of this work is to present four years ofexperience, based on 157 procedures performed on pre-selected patients submitted to cardiac resynchronizationtherapy, utilizing a simplified technique of coronary sinuscatheterization using the radiological anatomy andintracavitary electrography, demonstrating the success rate,

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complications and the total time of the utilization ofradioscopy.

METHOD

Study CharacterizationThis study was performed in the Clinical and

Cardiovascular Surgery Service “Prof. Dr. Sérgio Almeidade Oliveira” of the Hospital Real and Benemérita SociedadePortuguesa de Beneficência de São Paulo. The data collectedwere of patients submitted to biventricular pacemakerimplantation from October 2001 to February 2005. The studywas divided into three phases of observation for theevaluation of the success rate and time of utilization ofradioscopy. The first phase was from October 2001 toSeptember 2002, the second was from October 2002 toSeptember 2003 and the final phase was from October 2003to February 2005.

Population One hundred and fifty-seven patients with dilated

cardiomyopathy were studied with ages between 26 and 84years (average age from 55 ± 16 years). Sixty-eight (43.5%)of the patients were female and 89 (56.5%) male. Fifteen(9.8%) patients presented permanent atrial fibrillation and16 (10.5%) patients had definitive pacemakers previouslyimplanted for the treatment of bradyarrhythmias.

Inclusion criteriaThe inclusion criteria were: 1) patients with dilated

cardiomyopathy (DCM) and functional class III congestiveheart failure (NYHA) or IV refractory to the optimizedmedicinal therapy; 2) patients with DCM in which there wasno possibility of surgical repair (myocardial revascularization,valve replacement, left ventricular aneurysm resection orcongenital heart diseases); 3) patients without primaryindication for the reestablishment of heart frequency or ofatrioventricular synchronism; 4) exteriorized interventricularconduction disorders such as left branch or right branchstandard blocks associated with antero-superior divisionalor left branch block exclusively induced by right ventricularheart pacing; 5) duration of the QRS complex greater than orequal to 130 ms.

Exclusion criteria1) Infarction or unstable angina in the previous three

months; 2) acute myocarditis; 3) pregnancy and 4) drugaddiction or alcoholism.

Surgical procedureAll procedures were performed under local anesthesia

and when necessary under sedation, depending on the

degree of congestive heart failure and on the tolerance toan extended time in the decubitus position. Patients receivedprophylactic intravenous antibiotics one hour before theprocedure. They were placed in the horizontal dorsaldecubitus position, with electrocardiographic monitoringwith all the electrodes positioned on the right hemi-thoraxwhen the surgery was performed on the left (gold standard),or left when the surgery was performed on the right (incases in which it is impossibility to implant on the left sideor when the patient already had a definitive pacemakerimplanted on the right), so that all the electrodes were farfrom the heart image (two leads in the right deltoid region,anterior and posterior and one lead on the anterior-left axillaryline in the seventh intercostal space). The D2 bipolarderivation was utilized and the active lead was always placedin the deltoid region.

The first lead was placed in the right ventricle (RV),followed by the right atrium lead, both, when possible,through the left cephalic vein. When it was impossible topass one or both the leads, a new venous puncture wasperformed in order to obtain a passage. These leads (active)were placed in the traditional sites (atrium lead in the rightauricula and the right ventricle lead at its tip) or whereinitiation of stimulation, sensitivity and acceptableimpedance were identified. In the cases in which there wereindications for the implantation of associated implantablecardioversion-defibrillators (ICD), passively fixed doublespring leads were utilized, placed at the tip of the rightventricle. In patients with previously implanted doublechamber pacemakers, only a puncture for the left ventricularpacing lead was made. The last lead to be placed was thecoronary sinus lead to stimulate the left ventricle. In ourstudy Aescula 1055K (St. Jude Medical), Attain 2187 or 4193(Medtronic) and Corox+LV-H or Corox OTW (Biotronik)leads were utilized. This lead was passed into the subclavianvein and catheterization of coronary sinus was obtainedfollowing a radiological image of the anatomy usingfluoroscopy from a left anterior oblique view, at an angle of35 degrees and unipolar intracavitary electrography obtainedby connecting the coronary sinus lead to the guide lead ofthe electrocardiographic monitoring (Figure 1).

The lead was adjusted in compliance with the anatomyof right atrium. Its adaptation was achieved by shaping itsguide wire (Figure 2).

After shaping, the lead was placed in the low atrial septumregion. In this position, the lead was moved slightly to thetop and bottom (utilizing radiologic anatomy), forwards andbackwards, by anti-clockwise and clockwise rotation,respectively (utilizing intracavitary electrography). Regionsnear to the atrioventricular ring gave well-definedelectrograms with the presence of both atrial and ventricularcomponents.



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In patients who presented with sinusal rhythm, the atrialcomponent in the region of the coronary sinus ostium wasisodiphasic (Figure 3A). The more the lead went backwardsand distant from the CS ostium, the atrial component becameprogressively more negative (Figure 3B). On the other hand,the more the lead came forwards and distant from the ostium,the atrial component became progressively positive (Figure3). In this situation, it was not rare to pass through thetricuspid valve and migrate to the ventricle, creating highventricular potentials, eventually inducing non-sustainedventricular tachycardia.

It is known that the right atrial intracavitary electrogrampresents different morphologies and components that aredependent on the arrangement of the leads in its differentanatomical regions. High regions of the right atrium presentwith predominantly negative potentials, mid-regions of theright atrium present isodiphasic potentials and low regionsof the right atrium present predominantly positive potentials[12] (Figure 4 A, B and C).

Fig 1 - Photo demonstrating the procedure to achieve the unipolarintracavitary electrogram. Observe that the distal annulus of theelectrode is connected to the explorer electrode by means of a lead.

Fig. 2 - Guide wires with different formats (curves of different sizesand shapes) to adapt to the variations in the size and anatomy ofthe atria.

Fig. 3 - The upper trace shows a surface electrocardiogram of 25mm/s. The lower traces show unipolar intracavitary electrogramsobtained during the procedure, with an electrode placed in theright postero-septal region. (A) Intracavitary electrogram obtainedin the coronary sinus ostium. (B) Electrogram obtained near to,but in regions behind the coronary sinus ostium. (C) Electrogramobtained, near to, but in regions in front of the coronary sinusostium.



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After catheterization of the coronary sinus ostium thelead was placed in a tributary vein of the coronary sinus,utilizing the shape of the guide utilized for the catheterizationof the ostium or in specific cases a new guide wire in an “S”shape was introduced into the lead, facilitating its placement.

The choice was made with preference to left ventriclelateral and posterior wall veins, followed by the stability ofthe catheter, absence of diaphragmatic pacing with maximumpacing of 10 Volts, sensitivity pacing thresholds andimpedance of left ventricle and biventricular, in cases ofgenerators without independent exits.

RESULTS

Left ventricular pacing was successfully obtained in allpatients. In 11 patients left ventricular pacing was notobtained using the transvenous method as the first surgery,in sixpatients because of the impossibility of catheterizationof the coronary sinus and in five patients because of aplacement error in one of the tributaries of the coronaryvenous sinus. These patients were immediately submittedto the implantation of epimyocardial leads by thoracotomy.Five of the patients submitted to epimyocardial leadimplantation presented, after a mean time of 29.4 ± 4.6months, excessive increases in the electrode commandthreshold for left ventricular pacing. They were submittedto re-interventions to attempt transvenous pacing again andthis time success was obtained in all five cases (Figure 5).

Fig. 4 - Diagram illustrating the right atrial cavity, demonstratingthe position of the electrode in the high, middle and low regions ofthe right atrium and the resultant vector of depolarization. To theleft is a diagram showing the intracavitary electrogram obtainedin the three situations. (A) Electrode placed in the region behind thecoronary sinus ostium (high right atrium). (B) Electrode placed inregion of the coronary sinus ostium (middle right atrium). (C)Electrode placed in the region in front of the coronary ostium sinus(low right atrium). (CS= coronary sinus ostium), FO= fossa ovalis,LCV= inferior vena cava, UVC= superior vena cava, VAN =ventricular atrial node, ASN = atrial sinal node, RA= right atrium.

Fig. 5 - Radioscopic image of the left anterior oblique position of apatient who was submitted to a reintervention of transvenous leftventricle pacing. Observe the black arrow showing an abandonedepicardial electrode and the red arrow showing the transvenouselectrode placed in the posterior region of the left ventricle.

The catheterization of the coronary vein with theutilization of the radiologic anatomy and intracavitaryelectrogram was successfully performed in 150 procedures.At the moment of the catheterization of the coronary sinusostium in patients who presented sinusal rhythm (136



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patients), the atrial component was seen to be isodiphasicin 133 (97.7%) of them and predominantly positive in three(2.3%) patients. The placing of the lead in coronary sinustributaries was successful in 145 (92.9%) procedures, withan average time of radioscopy of 18.27 ± 15.46 minutes.The success rate progressively increased with theexperience of the surgeon. In the first phase of observation,the success rate was of 55.5% with an average time ofradioscopy of 43.6 ± 18.6 minutes, in the second phase itwas of 92.6%, with a mean time of 18.14 ± 13 minutes and inthe third phase it was 98.2%, with an average time of 13.76± 4.66 minutes. In five patients, in which cannulation ofthe coronary sinus was obtained, the placement of theleads was not successful: in four cases due to the difficultyof placing the lead in a tributary of the coronary venoussystem and, consequently, it was impossible to haveacceptable thresholds and in one patient due todiaphragmatic stimulation in the only place in which it waspossible to achieve stimulation of the left ventricle. Ineleven procedures, pacing of the left ventricle was obtainedthrough the implantation of epimyocardial leads bythoracotomy.

Difficulty in cannulating the coronary sinus wasexperienced in 20 patients, in spite of the adequateintracavitary potentials and the placement using radiologicalimaging. In six cases maneuvers of the lead and guide wirewere performed enabling the passage of the lead through theostium and the lead was placed in the coronary sinus. Ineight cases, a stiffer guide wire with sharper curves was utilizedthereby assisting the passage of the lead. In 39 patients wehad difficulty with the insertion of the lead, probably wherethe great cardiac vein drains into the coronary sinus. Thisproblem was solved in 30 procedures by successivemovements of the electrode and its guide wire. In nine cases,another straighter and more rigid guide replaced the pre-shaped guide. In 12 cases the electrode had to be repositionedafter removal of the guide accidental displaced it. Ten patientspresented diaphragmatic stimulation and the electrode wassuccessfully repositioned in nine patients. Three patientspresented transitory total atrioventricular blocks aftermanipulation of the electrode in the right ventricular cavity,making temporary ventricular pacing necessary. In threecases, there was displacement of the atrial electrode duringmanipulation of the coronary sinus electrode, making itsrepositioning necessary.

In two cases, the left side implantation was interruptedand the leads were successfully implanted from the right;one was because of the impossibility of advancing theelectrodes up to the right cavities due to the presence ofpersistent left vena cava and narrow coronary sinus,making the passage of the three electrodes impossiblethrough the same access route.

COMMENTS

Cardiac resynchronization therapy has demonstratedgood results in the treatment of pre-selected patients withcongestive heart failure [1-3]. The traditional method of leadimplantation for left ventricular pacing is epimyocardial bylateral or subxiphoid thoracotomy or by thoracoscopy. Thesemethods have already been demonstrated as efficient andwere routinely used before the invention of transvenouselectrodes for epicardial pacing with endocardial [13]. Themain obstacles to the routine epimyocardial implantation ofleads for left ventricular pacing in patients with enlargedcardiomyopathy and congestive heart failure are the risksassociated with general anesthesia and post-surgicalmorbidity [14]. Currently, the transvenous method using anendocardial access is the gold standard because it reducesthe complexity of the surgery and, consequently, itsmorbidity and time of hospital stay [7].

One of the main limitations of the application of thetransvenous technique is the catheterization of the coronarysinus and the placement of a special electrode in one of itstributaries for left ventricular pacing [5,13]. The success ofthe implantation depends on multiple variables, includingexperience and technique of the surgeon, anatomy of thecoronary sinus and availability and variety of specialmaterials [6].

In spite of the great advances in technology andevolution in the implantation techniques using sheafsystems, special systems of guide wires such as side-the-wire [11] and over-the-wire [8, 13], or proposals of coronarysinus cannulation guided by electrophysiologic catheters[7] have been demonstrated to be efficient. Even so theproposed techniques, whether by sheaf associated withcontrast, special guide wires or inadequate intracavitaryelectric signals, still only utilize radiologic anatomy and aseries of trials and errors when cannulating the coronarysinus. Taking into account this limitation which still remains,the authors present the experience of just one center, of atechnique that attempts to facilitate the cannulation of thecoronary sinus based on the radiologic imaging of theanatomy and intracavitary electrogram, emphasizing the atrialelectrogram morphology of patients who present withsinusal rhythm.

The choice of the left side for the procedure was due totwo reasons. Firstly, because of the facility of routing thelead to the site of the pacemaker in cases in which the pacinghad to be epimyocardially performed by thoracotomy. Thesecond is that, eventually, patients present with a persistentleft vena cava with atresia of the coronary sinus ostium[14,15], making implantation to the right impossible. Wechose to implant conventional electrodes for right ventricularand atrial pacing, respectively, as they serve as points of



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anatomical definition and because, during the manipulationof the electrode in the patients with blocks of the left branch,there is a risk of injury to the right branch, causing totalatrioventricular blocks and the necessity of temporarycardiac pacing, as has been described in the literature [6]and which occurred in two of our patients.

With the utilization of the radioscopy using a left anterioroblique (LAO) view at 35º, a bidimensional anatomicalrelationship between the tricuspid and mitral annuli wasobtained, clearly demonstrating the lateral and septal wallsof the right atrium. With the help of the intracavitaryelectrogram, we identified the proximal regions of theatrioventricular annulus, demonstrating atrial and ventricularintracavitary electrograms with ratios of 1:2 or less [16]. It isknown that the coronary sinus ostium is in the right postero-septal or proximal regions, or even in the atrioventricularannulus itself, the electrode was placed in this region byutilizing the guide wire of the electrode which had previouslybeen shaped, while watching the atrial and ventricularelectrogram.

Manipulation of upper and lower regions was easilyperformed using the radiologic anatomy. However, theradioscopy provided bidimensional images andconsequently mobilization in the anterior and posteriorregions could not be controlled by it. Thus, these movementsof the electrode were accompanied based on the atrialcomponent of the intracavitary electrogram in patients withsinusal rhythm. It was observed that, in the coronary sinusostium, from where it was possible to catheterize thecoronary sinus, the intracavitary electrogram was seen tobe isodiphasic in 133 of the 136 procedures, in which patientswere in sinusal rhythm and catheterization of the coronarysinus was possible. In these patients it was still observedthat a slight movement of the electrode to the posteriorregion turned the atrial component predominantly negative,and that displacement to the anterior region made itpredominantly positive, positions that were checked withthe radioscopy in right anterior oblique (RAO) view. Apossible explanation for these observations was found: it isknown that the resulting vector of the right atrialdepolarization initiates in the sinusal-node region and isdirected downwards, forwards and a little to the left [15,17].

As the coronary sinus ostium is in the posterior regionof the right atrium, in front of and to the side of the lowervena cava valve and in front of the septal cuspid of thetricuspid valve [18], this is, due to its anatomic position,perpendicular to the vector of atrial depolarization. As theatrial electrogram obtained with the electrode is unipolar,the placement of this on the coronary sinus ostium wouldput it in an almost vertical position creating isodiphasicpotentials [17]. In this situation, moving the electrodebackwards, the electrode would tend to observe the tail of

the vector, and the signal would become more negative and,forwards observing the tip of the vector, the signal wouldbecome more positive [17], as demonstrated in the Figure 4.

Galvão Filho [12], in 1990, also demonstrated that theatrial electrogram varies according to its location in the rightatrium. However, he utilized a different manner to explainthe anatomic structure of the right atrium based on abidimensional image from the author. What Galvão Filhodenominated as high right atrium and low right atriumcorrespond to the upper and lower regions (close to thetricuspid ring) of the right atrium. In the radiological anatomyutilized by the authors (left anterior oblique view), posteriorregions to the coronary sinus ostium correspond to theupper region of the right atrium and anterior regions to thecoronary sinus ostium correspond to the lower region.

Our success rate of 94.4% was similar to published rates[6-8] and clearly showed a learning curve with a successrate in the first year of 55.5% and 98.2% in the last year. TheEuropean register of CONTAK revealed with details thatthe average duration of the procedure and the success ratewas directly proportional to the experience of the surgeon[8]. Surgeons that performed more of 20 implantationsachieved the procedure in shorter times associated withshorter times utilizing the radioscopy. The average time ofimplantation was 90 ± 38 minutes with a radioscopy time of27 ± 21 minutes. Our total average time of radioscopy was18.21 minutes. Compared to the literature, our total averagetime of radioscopy was shorter than those cited by Kautzneret al. [6], Butter et al. [10], Purerfellner et al. [7] and Yee et al.[19]. This can be explained by the fact that many surgeonswere involved in these works and, in some cases, manycenters, thus the results were influenced by the experienceof each individual surgeon. In our work, the results wereinfluenced by the learning curve of only one surgeon. Also,in this study, the sheaf was not utilized for catheterizationof the coronary sinus instead it was directly cannulatedwith an electrode itself, thus reducing the chances ofdisplacement with the removal of the sheaf whichconsequently increases the time of the procedure [4].

Analyzing, the intra-operative difficulties in 20procedures we experienced difficulties in the cannulation ofthe coronary sinus ostium. In six procedures, thecannulation was not possible and, in five patients, theplacement of the electrode in one of its tributaries was notpossible, demonstrating the importance of the anatomicvariations of the coronary sinus ostium [6], of the angle andof the caliber of its tributaries, and even the presence andanatomy of a Thebesios’ valve, in the catheterization of thecoronary sinus. In one study of 143 patients, 62.9%presented the valve; in 73 patients the valve had a semi-lunar shape, in 10 cases a septal shape and in seven cases ashape like a crest [20]. In 39 procedures, there were difficulties



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BIBLIOGRAPHIC REFERENCES

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3. Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR,Loh E et al. Cardiac resynchronization in chronic heart failure.N Engl J Med. 2002;346(24):1845-53.

with the forward movement of the electrode through thecoronary venous sinus, near to the junction of the greatcardiac vein, a probable location of the Vissencius’ valve asfound in 87% of the studied cases by Lundinghausen et al.[21], also demonstrating the importance of this valve in theimplantation procedure of the coronary sinus electrode.

CONCLUSION

The implantation technique employed by the author, thatutilizes intracavitary electrogram and radiological anatomy,proved to be safe and efficient for the cannulation of thecoronary sinus ostium and its placement in one of itstributaries with a short radioscopy time.

4. Fatemi M, Etienne Y, Gilard M, Mansourati J, Blanc JJ. Shortand long-term single-center experience with an S-shapedunipolar lead for left ventricular pacing. Europace.2003;5(2):207-11.

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6. Kautzner J, Riedlbauchová L, Cihák R, Bytesnic J, Vancura V.Technical aspects of implantation of LV lead for cardiacresynchronization therapy in chronic heart failure. Pacing ClinElectrophysiol. 2004;27(6 pt 1):783-90.

7. Purerfellner H, Nesser HJ, Winter S, Schwierz T, Hornell H,Maertens S. Transvenous left ventricular lead implantationwith the EASYTRACK lead system: the European experience.Am J Cardiol. 2000;86(9 suppl 1):K157-64.

8. Neuzner J, Pappone C, Aurichio A et al. Learning curve for thefirst 1000 over-the-wire left ventricular transvenous leadimplants-a Europe experience. Eur J Heart Failure2001;3(suppl.1):S13.

9. Curley J, Lamba S, Moulton K et al. Does the availability ofleft heart lead and delivery system options matter for cardiacresynchronization therapy? Pacing Clin Electrophysiol.2002;24(Pt. II):597.

10. Butter C, Gras D, Ritter P, Stellbrink C, Fleck E, Tockman Bet al. Comparative prospective randomized efficacy testing ofdifferent guiding catheters for coronary sinus cannulation inheart failure patients. J Interv Card Electrophysiol.2003;9(3):343-51.

11. Walker S, Levy T, Rex S, Paul VE. The use of a “side-wire”permanent transvenous-pacing electrode for left ventricularpacing. Europace. 1999;1(3):197-200.

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13. Auricchio A, Klein H, Tockman B, Sack S, Stellbrink C,Neuzner J et al. Transvenous biventricular pacing for heartfailure: can the obstacles be overcome? Am J Cardiol.1999;83(5B):136D-42.

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16. Niebauer MJ, Daoud E, Williamson B, Man KC, StrickbergerA, Hummel J et al. Atrial electrogram characteristics in patientswith and without atrioventricular nodal reentrant tachycardia.Circulation. 1995;92(1):77-89.

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19. Yee R, Pappone C, Maertens S et al. Clinical experience withover-the-wire left ventricular pacing lead for biventricular pacingin heart failure patients: multicenter report. Can J Cardiol.2001;(suppl C):89C-288C.

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technical aspects of lead implantation for left ventricle

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