[1] Alright, thank you very much Dr. Hawthorne. We’re gonna shift gears back again. And I’m gonna spend my time sort of reiterating some of the things that I think you’ve already seen or heard for left ventricular lead placement where we have a fair amount experience on, and then we can see if I can pass on anything that you guys know or don’t know here. Let’s see. So, you’re supposed to go right. [2] Okay, there you go. Here are my disclosures. [3] Okay. So, I usually like starting a biventricular, left ventricular lead implant with this case. This is of course somebody with left SVC who got a biventricular pacemaker as part of the PAVE Trial. This is actually the first patient I enrolled in the PAVE Trial. Of course, if you’re doing a study patient and it has to be a left SVC syndrome, right? So, but my reason for showing this usually is the fact that, one, I’m stupid because I blew up a balloon in a left SVC coronary sinus and I have no idea why. I could have put a Foley catheter in there and not occluded the thing and blood’s going the wrong way. So, I’m not sure why I did that. But the point is, is that, you know, this isn’t a day where you’re free-handing leads and using just allied driven systems and it was a little bit harder, right. Now, with all in the delivery systems that we have, left ventricular lead implantation has gotten incredibly easy and so I’m gonna show you the ways sort of how I do things and I think evolves to this their own sort of ways and maybe I can show you a couple of tricks of the trade. [4] So, success rates for biventricular pacing, traditionally from our trials as always you see everything about 90% and I think this is now old data, right? Because everyone has accumulated a whole lot of experience and similarly, you’ve got these ridiculous long implant times, three hours or so. And we just don’t see that very often now and obviously there are cases with challenging anatomy but our average biventricular case is about 30 to 40 minutes and that’s total skin to skin and it’s become a reliable reproducible procedure. But that’s where a sort of experience comes in. And I think this is just another procedure like everything else is. People accumulate experience and have a learning curve overcome, you get your times down and I think of course, that’s incredibly important for a variety of reasons. [5] My former institution in Las Vegas, this was actually, you can see his LVAD attached to his belly there. We actually did a fair amount of biventricular pacing starting with all the clinical trials. And it’s interesting. I have to actually pull our data before I left Las Vegas in January of 2005. So, in 2004, we put in 338 biventricular systems and you can see the mix there, 86% CRTDs and 14% CRTPs. And the key implant success rate was 98% but the caveat there are those eight acute failures, six were from operated was less than 50 implant experience. There were only two failures and somebody with any real experience. And so, of course, there’s still revisions that need to be performed and these have also decreased dramatically with now that we have bipolar leads and programmable vectors and things that you can avoid phrenic nerve stimulation. [6] So, I’m just gonna share a couple of trick that or my sort of take on left ventricular lead implantation. I think peripheral venous access is incredibly important for a variety of reasons but the key here I think is you need to stay lateral. So, whether you’re doing a cephalic vein cutdown or you’re doing an axillary puncture you should stay lateral, away from the clavicle. The reason for that is especially important in left ventricular lead. It’s not that you’re gonna have issues with crush but you need to manipulate a whole lot of equipment, right? So, you’ve got sheaths that you’re deploying in the right atrium and you need to torque them a lot and get into the coronary sinus. And if you’re very medial, you just don’t have that ability to torque. Of course, coronary sinus access that tends to be a usual problem ion people who are just learning how to do this. When we have people come at out site for training centers, this is their biggest sort of obstacle. There’s a lot of tricks that that you can use there. Left ventricular branch vein access I think is actually the more challenging thing once you overcome the coronary sinus business. Then, of course, like everything else positioning and testing and then removal of the guide sheath. [7] So going over the anatomy is very important. Let’s see if that laser pointer is actually still up here. Oh, it doesn’t matter. The point is, showing this is that, is to stay lateral. And I cannot underscore that enough. The mouse is, oh, wonderful. So, looking an LAO and I still do this in every single case. I confirm my lead position with LAO in at 30 to 45 degrees and you want to be out here and I think that is incredibly important knowing that you can probably do some harm in placing the lead in the anterior lead or the anterior vein, right? Because of presystolic anterior papillary muscle activation and you can actually worsen mitral regurgitation. So, you get a lead out here or you don’t get a lead in there. Send the patient to surgery. It is very easy for the surgeons to place an epicardial lead. So, if you do not have a lateral branch vein or you cannot get the lead out there, don’t compromise and put in anterior position or a straight posterior position. [8] Some old data that basically just shows that you increase contractility in the mid-lateral wall and this is still fairly robust and if you look at some of the energetic state from David Cassidy’s lab, I think that is fairly robust. And if you’re in the lateral wall, it’s not like you’ve got this one individual’s sweet spot but if you go lateral and the patient truly has dyssynchrony, it’s going to work. [9] So, much like what you’ve heard already, I use separate access for the left ventricular lead because I don’t want to have to manipulate anything once I’ve positioned my left ventricular lead. So, for a single chamber ICD, I do cephalic cutdowns on everybody. But for a biventricular system, I do axillary puncture and I will typically stick twice and retain for the RV and RA but the left ventricular lead is separate. And I think that’s a useful sort of habit to get into. And again, stay lateral because you’ve gotta manipulate a lot of equipment. This is especially important with upgrade so I’ll tell you that, you know, you can have brand new virgin implant and you look forward to that case because it will be easy. If you have an upgrade, you have to block out time ‘cause you have no idea what you’re up against. Frankly, there’s so much variability. [10] So, the point is to stay here. Then, we actually go for is through axillary puncturing instead of going subclavian. [11] So in the old days, we use to freehand a lot of leads, the so called off label cases that we’re never suppose to talk about. And I will be the first person to admit that I wish I didn’t do them but we did. But there’s some trick sometimes, you actually have to freehand systems because the spasm or big valves are there and I’ll show you some examples of that. Now, we have over-the-wire systems and this is made a lot easier. We have a whole series of coronary sinus guide sheaths that are now available and my advice to you is to stay with something that you know and get very familiar with because unfortunately, you cannot predict anatomy prospectively, right? But if you get used to using one particular thing over and over again, most of the systems are pretty adaptive so you can make that adapt to every patient’s given anatomy. I think EP catheters are still very useful to get you get out of jams. This is how we first started doing it. Now, even though I’ve seen 99% of the time, we don’t need to use an EP catheter, we still pull it out from time to time. [12] So, obviously, anatomy is very variable. Let’s see here. And so if everybody was like this patient here, life would be good. The most challenging anatomy in my mind are these, where you’ve got the high take-offs and especially in the large right atrium where the floor is displaced and you don’t have guide support. And I think that’s why it’s very important in those patients to get your sheath well into the coronary sinus and if a branch vein is sizable enough actually to get that sheath into the branch vein as you saw earlier, to get that guide support because after all, this is push-pull just like angioplasty. [13] So accessing the coronary sinus, people use lots of different things. I’ve never found steerable catheters particularly useful because the ones that are out there have too short an angle of deflection. I typically use a coronary sinus decapolar catheter if I’m pulling in an EP catheter just works for me. I’ve never found EP recording particularly useful. Tricuspid valve annular signals look the same as the coronary sinus and since you know when you’re in the coronary sinus. The question is getting with across the ostium if you have valve or what not. Appropriate sheath selection. And my caveat there is you really wanna use the sheath that’s very flexible at its tip because of the risk of dissection. We use an inner lumen sheath for every case now and that’s how we actually access the coronary sinus and then get into a branch vein and I think that’s useful because you have something else to vary sort of another angle or another variable or angular freedom. Balloon catheters we used to use on everybody but I’ve actually found this is one trick I can tell you that if you do a sub-selective branch venography, it’ll actually light up every single branch. And using a balloon catheter, you can often miss things because you’re either occluding a branch or you don’t completely occlude the coronary sinus if it’s too sizable. And it can be a little misleading. You think you’ve done a good a venogram and you think you’ve seen everything and you haven’t. In my experience, if you sub-select and inject, you will see every branch available. [14] I’m gonna skip through some of the venograms since mine are not as good quality. In fact, they’re actually very old and grainy. But this is just an example as you already saw of accessing the coronary sinus with a decapolar catheter. And it’s actually a fairly easy thing to do because it’s very recognizable that once you into the coronary sinus, it just sort of springs across. But the key here to look is use some of the tricks as far as identifying where the coronary sinus is. If you’re looking an LAO, the coronary sinus is almost invariably going to be at the border of the spine. And this motion that sort of rocks up and down tells you that you’re close. So in this particular case, we’re sort of negotiating a valve and as soon as you get into the body of the coronary sinus, it will spring across. Of course when you’re stepping on fluoro and trying to do this it always takes longer, right? So I think we’ll get across right about now. Let’s see. There you go. No, I’m not able to advance. [15] There we go. As I mentioned, I typically use an inner sheath for everything now. And so here is a venogram where you’ve got a coronary sinus sheath in the coronary sinus if this will ever go. And you can see you’ve got a very nice branch vein here but actually it paced the diaphragm and we’re actually had to look for a branch up here. And this is also fairly typical. I don’t waste time anymore trying to wire a branch vein by itself. I will always sub-select that branch vein. And the reason for that is as the veins often come off backwards and you can spend a lot of time trying to negotiate that branch vein with a wire if you’re just trying to do it this way. But if you sub-select that branch with an inner lumen catheter, it saves you a heck a lot of time. And so that’s what we did in this patient eventually. You see this smallest branch over here. The other thing, the other reason why it’s useful, if you sub-select the branch vein actually, you’ll get a true idea of the size of the vein. And it’s sometimes a little misleading if you don’t that the branch look smaller than it really is. Let’s just see if it will light up once with sub-selection. There you go. See how much more, how much larger this looks when you’ve sub-selected in there compared to the previous shot. Let’s see if I can advance this. [16] Okay, so some difficulties. I’ve already talked some of the anatomy if you have and anterior-inferior, posterior-superior displacement in the coronary sinus. Valves are always interesting. It’s not uncommon to come across the valves and they have every sort of size, shape, color you can think of. We’ve seen valves that are completely dense structures that you can see actually without even contrast lining upon fluoro. They can sometimes be trabeculated or have sort of holes in them that you through and you’re wondering why you were having problems manipulating your sheath through. And it’s those kind of problems that then lead to dissections and so you have to very careful her in crossing them. The proximal coronary sinus is also muscular structure and everyone sort of forgets that. And so this structure can spasm and it’s another reason why sometimes you can’t advance the sheath or even a wire in some cases. [17] Then again, the issues of dissection. [18] So, let me just show you and let’s skip ahead here in the interest of time. This is obviously a trichrome stain and this is the proximal coronary sinus of the true coronary sinus where you see all this muscle here on trichome stain. Here’s a valve with the... which is invariably present in everybody, typically two to three centimeters in from the ostium and that’s of course into the junction from the coronary sinus to the greater cardiac vein. [19] You can see this with ice. In my experience, I don’t think this is particularly helpful in trying to guide you to the coronary sinus. But here in this case, you can barely see this outline of a large floppy kind of a structure, that’s the vein or the valve here. [20] So, let’s see if this would play through. I apologize for this when you really can’t see it but there’s a little whitish structure right in here, right next to that balloon. That’s a valve. You could that it’s sort of moving with blood flow here. [21] This is an example of spasm in the coronary sinus. You can see that even though you have a sizable coronary sinus and actually the mother of all branch veins out here, the entire coronary sinus would spasm down with the sheath in the proximal portion. And in this particular case, it was to the point where you couldn’t even put an angioplasty wire through this if you had the sheath here. And so what we have to do is keep the sheath outside the coronary sinus, wire this, and then push-pull the lead across to this very large branch vein. [22] Okay, so obviously we have a lot of problems with the LV anatomy, lack of branches. The angle of take-off is the thing that gives people a hard time and that’s why again, I’ve emphasized you need guide support. The way I’ve overcome these nowadays is now that we have sheaths with very flexible tips, I would sub-select with an inner lumen catheter and then try to track the other sheath into the branch vein so I can get guide support when I’m pushing a lead through a smallest vein. Obviously, we use a little bit of wire pretty much for everything and then there’s some other things we do when we’re desperate whether it’s angioplasty or stent placements, putting in multiple leads or pericardial access even. [23] I’m gonna [24] skip through some of the stuff here. You’ve already seen an example of this so I’m gonna skip through that. [25] This is a patient, a 52-year-old guy with an idiopathic dilated cardiomyopathy. His EF is about 22% and he has significant left ventricular dyssynchrony on tissue Doppler. And we actually have the advantage of having echo in the lab and he had this sort of this posterolateral position and this by itself didn’t exactly correct his dyssynchrony. But we kind of like this position as compared to this sort of anterolateral position. But what we did actually just for fun of it clipped them both up together and actually had tremendous reduction in his dyssynchrony indices. It’s just an example of some tricks that you can do. [26] This is an example of a patient. I’ve done a few of these now where I actually access the pericardium directly. In somebody with a very small branch vein and obviously a virgin chest here, what you do is take an inner lumen catheter and basically to the point where you’re standing and then get a wire down and actually got a lead into the pericardium directly. The lead ended up being a little bit more proximal when we had the thing finally done. It actually had very good numbers, 1.4 both threshold. And the patient had some pericarditis symptoms, did not develop a clinical effusion on echo and then has done very well actually. [27] This is somebody who had CABG and history of redo CABG who had at one point, probably a beautiful lateral branch vein but the portion over here was completely sclerotic and you can see all the blush is that sort of collaterals that’s sort of developed. But in this case, we’re able to actually wire that and I tried angioplastying it first but unfortunately, even after just angioplasty, you still don’t really have much of a lumen. So, here is an example of putting a stent in this particular branch actually and this actually opened it up very nicely to the point where we then able put a lead out in here. This a little bit blown up there. In my experience and other people have reported otherwise, angioplasty itself is not particularly useful tome. I think the veins are just thin walled and it collapses down. And sometimes, the reason why you have or you can’t get a lead through I think is because essentially that we go intramuscular and then a balloon won’t. In fact you can bust a balloon doing that. But stents work very well in this case. And since we now need to have a reason to find or some sort utility for bare meatal stents, that’s my solution to the problem here. [28] Again, emphasizing, once you’ve achieved a lateral position, stability of course is key. And I always actually watch my lead for some period of time after everything is out and taking the sheath all the way back and the angioplasty wire all the way back before I test and before I decide whether I’m taking that position. Just watching it with motion in the sort of the way the lead is actually gonna end up sitting. Chronic thresholds are an interesting issue and this is why I go to all these lengths to put leads in the lateral wall and try to get good thresholds because there’s no doubt that transvenous leads it seems now have a much better experience compared to traditional surgical epicardial leads right in terms of chronic thresholds. That at least experience over several years anyway the threshold stayed down. [29] Diaphragmatic pacing of course is an issue. We always check with fluoroscopy ‘cause sometimes it can be very subtle. Often times obviously it’s not. [30] Skipped Slide. [31] Let’s just skip through this. I really don’t have a preference using a peel-away system versus backing out a sheath. It’s just something that you’ve become accustomed to and its’ whatever works for you. But the key part and I think a lot of people have problems in doing this and this is where people dislaunch lead is maintaining the right amount of lead slack. You cannot leave too much lead slack on a left ventricular lead because it will prolapse on the floor of the right atrium and essentially flop you’re whole lead out. So, it’s just a little tiny J is basically what I leave at the ostium of the coronary sinus and that’s where we leave it. And to watch that over and over, and over again. [32] So I’ll conclude once again the importance of peripheral venous access is incredibly important. Coronary sinus access I think overcome with all of our sheath and the key here is I think it’s just become familiar with your anatomy and you can pretty much overcome that. Guide support, guide support, guide support critically important if you’re gonna get leads out in the LV branch veins. Be careful in removing your guide sheath to look at fluoro and not you’re hands when you’re pulling out your sheaths. And this is the thing I tell the people that come in for training actually is that you do whatever works for you. You do it over and over, and over and over, and over again. Make your system work and that make that adaptable for you. And that’s the way to kinda get through these cases. So I will conclude with that. Thank you very much for your attention. [33]

Rahul Doshi 210B-ARS Left Ventricular Lead Placement Tips and Tricks for Device Implantation