pre-procedural preparation and crt implantation tips and tricks
TRANSCRIPT
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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.
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Outlines
Pre-Procedural Preparation
CRT Implantation Tips and
Tricks
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Outlines
Pre-Procedural Preparation
CRT Implantation Tips and
Tricks
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Pre-Procedure preparation
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Pre-Procedure preparation
Baseline clinical data
Image techniques
Electrical assessment (resting ECG)
Pre-implantation medical management
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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
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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
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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
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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)
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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
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KCGMH data
Can J Cardiol. 2013 Sep;29(9):1110-7.
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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
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Outlines
Pre-Procedural Preparation
CRT Implantation Tips and
Tricks
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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
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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
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CXR
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CS Cannulation Catheters
Metronic
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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
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PPM wound area prepare
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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
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Venography
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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
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Cut-down or Puncture
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Cut-down or Puncture
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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
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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
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Position of RV lead
Optimal site still not determined
Mid septal or RVOT preferred by some
However DFT may be higher
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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
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Burkhardt, J. D. et al. Circulation 2007;115:2208-2220
Right atrial anatomy and
relationship to coronary sinus
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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
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Effect of CCWR rotation
First moves to the left
Then, moves downwards
Start here
From: Clinical Cardiac Pacing, Defibrillation and CRT by Ellenbogen
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Effect of CCWR rotation
Staring too low
From: Clinical Cardiac Pacing, Defibrillation and CRT by Ellenbogen
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Cannulating Coronary OS:
From below
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Cannulating Coronary OS:
From above
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Cannulation of CS OS
Materials used:
Outer Guide Catheter
Guidewire
EP catheter
Coronary catheter (JR, AL)
Inner sheath (Cannulators)
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Cannulating Coronary OS:
Our Way
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Cannulating Coronary OS:
Our Way
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Cannulating Coronary Os:
EP approach
Cannulation_Method3-EP_Approach.wmv
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Cannulation of CS OS
IEGM to confirm position
A / V > 1
Atrial signal at the end of the P-wave
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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
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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
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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
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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.
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Coronary venography
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Coronary vein
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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
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Selecting target vein
size
angulation
tortuosity
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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
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Quadripolar vs Bipolar leads
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LV leads-SJM
Lead Lead
body size
Polarity
QuickFlex
1258T
4.3Fr Bipolar
Quartet
1458T
4.7 Fr Quadripol
ar
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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
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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
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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
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Lead position
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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,
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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,
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Final positioning
RAO LAO
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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
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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,
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LV electrical lead position
SR, LBBB, QRS: 189 ms
LAO
50°
His
Bundle
RAO
30°
Earliest Ventricular
Activation
LAO
90°
Latest Ventricular
Activated Region
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Sites to avoid
Anterior (GCV) pacing
Apical LV lead position
Phrenic nerve stimulation
Scar areas
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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
![Page 63: Pre-Procedural Preparation and CRT Implantation Tips and Tricks](https://reader031.vdocuments.us/reader031/viewer/2022021922/588703f11a28ab4e3a8b6d07/html5/thumbnails/63.jpg)
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)
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Real Case (1)
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Real Case (2)
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Real Case (3)
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Real Case (4)
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Real Case (5)
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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
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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
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Removing Implant Tools
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Snap lead into lead
channel of slitter
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Slitting
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Incorrect Slitting
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Correct Slitting
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80
Incorrect Slitting
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Fixating the leads
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Connect CRT devices
CRT-PCRT-D
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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
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Thanks for your attention!!
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Pre-Procedure preparation
Europace (2012) 14, 1236–1286
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Pre-Procedure preparation
Europace (2012) 14, 1236–1286
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Pre-Procedure preparation
Europace (2012) 14, 1236–1286
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Methods of patient assessment
prior to CRT implant
Europace (2012) 14, 1236–1286
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CRT implant recommendation
Europace (2012) 14, 1236–1286
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CRT implant recommendation
Europace (2012) 14, 1236–1286