Efficacy of the Direct Wire Pacing Technique During a TAVR Through a Simple Electrocautery Plate

In recent years, several improvements have enhanced the procedures for transcatheter aortic valve replacement (TAVR). These include vascular puncture with ultrasound guidance, radial access as a secondary safety approach and noninvasive left ventricular pacing using the direct wire pacing (DWP) technique.1Burzotta F. Aurigemma C. Romagnoli E. et al.A less-invasive totally-endovascular (LITE) technique for trans-femoral transcatheter aortic valve replacement.Catheter Cardiovasc Interv. 2020; 96: 459-470https://doi.org/10.1002/ccd.28697Crossref Scopus (21) Google Scholar,2Lefèvre G. Jégou A. Dambrin G. et al.Comparison of transfemoral transcatheter aortic valve replacement performed with a minimally invasive simplified technique: "FAST" versus a standard approach.J Invasive Cardiol. 2019; 31: 300-306Google Scholar The latter technique was previously described for coronary angioplasty procedures.3Meier B. Rutishauser W. Coronary pacing during percutaneous transluminal coronary angioplasty.Circulation. 1985; 71: 557-561https://doi.org/10.1161/01.CIR.71.3.557Crossref Scopus (72) Google Scholar It offers the advantage of being less invasive because it does not require the placement of a right ventricular pacing lead. Thus, the risk of vascular complications and right ventricular perforation is reduced, even though they are low.4Faurie B. Souteyrand G. Staat P. et al.Left ventricular rapid pacing via the valve delivery guidewire in transcatheter aortic valve replacement.J Am Coll Cardiol Intv. 2019; 12: 2449-2459https://doi.org/10.1016/j.jcin.2019.09.029Crossref Scopus (47) Google Scholar Furthermore, a study by Faurie et al4Faurie B. Souteyrand G. Staat P. et al.Left ventricular rapid pacing via the valve delivery guidewire in transcatheter aortic valve replacement.J Am Coll Cardiol Intv. 2019; 12: 2449-2459https://doi.org/10.1016/j.jcin.2019.09.029Crossref Scopus (47) Google Scholar have shown that it reduces procedure duration, fluoroscopy time, and cost, while remaining effective and safe. The most common technique involves connecting the cathode to the valve delivery guide wire positioned in the left ventricle. The anode is connected to the patient's skin, typically using a needle. Some operators even directly connect the alligator clip to the skin. Unfortunately, the needle poses a risk to the operator, it requires an additional skin puncture for the patient, and its small size increases the risk of loss of capture in case of movement. Devices like the Electroducer are under development to improve the technique, particularly by eliminating the need for a needle. Here, we describe an additional option to the DWP technique using an electrocautery patient plate (Electrosurgical plate, split, 8180F; 3M Deutschland) as a replacement for the needle; this technique has already been mentioned among others.5Blusztein D. Raney A. Walsh J. Nazif T. Woods C. Daniels D. Best practices in left ventricular pacing for transcatheter aortic valve replacement.Struct Heart. 2023; 7100213https://doi.org/10.1016/j.shj.2023.100213Abstract Full Text Full Text PDF Scopus (0) Google Scholar For the DWP, the cathode of an external pacemaker was connected to the distal external end of the guide wire positioned in the left ventricle (Safari guidewire; Boston Scientific), using an alligator clip. The anode was connected to the electrocautery plate placed on the left chest of the patient (Figure 1), using another alligator clip. Efficacy of stimulation was tested before valve deployment. During the valve deployment, electric stimulation was delivered in asynchronous mode at an amplitude and a rate at the discretion of the operator, in general at high amplitude (20 mA). We report a retrospective single-center series of 102 patients who underwent TAVR using DWP. Of the 102 patients included between July and October 2023, 89 received a balloon-expandable valve (Sapien 3 Ultra; Edwards Lifesciences) and 13 received a self-expandable valve (Corevalve Evolut Pro+; Medtronic). TAVR were performed under local anesthesia and conscious sedation. The implantation success rate was 100%. There was only one instance of loss of capture across all procedures. No painful muscle contractions were observed under moderate sedation. No other side effect (eg, skin irritation and burning) was observed. Four patients required implantation of an electrosystolic pacing lead through a venous approach owing to persistent high-grade atrioventricular block. When this occurred, left ventricular pacing was continued during the placement of a lead. Six patients required a permanent pacemaker within 7 days. Our study remains retrospective without a control group, but it is worth noting a very low rate of loss of capture, which is highly satisfactory, considering the benefits of using a simple, cost-effective device (<$1) without any risk to either the operator or the patient. The study of our cohort demonstrates that the use of an electrocautery plate as the anode instead of a needle is a safe and effective method for the DWP technique during TAVR procedures. The authors thank the paramedics of the catheterization laboratory. The authors do not have any conflicts of interest to disclose. This research did not receive any specific grant from funding agencies in the public, commercial, or non-for-profit sectors.