Key result
Retrograde venography facilitates collateral vein puncture for CRT upgrade during subclavian occlusion, improving LVEF to 55%.
Why the study?
Lead-related venous occlusion can hinder CRT upgrade via His-bundle pacing in pacing-induced cardiomyopathy, prompting the need for techniques to overcome venous occlusion.
Does retrograde venography to navigate an occluded subclavian vein facilitate cardiac resynchronization therapy upgrade via His bundle pacing in a patient with pacing-induced cardiomyopathy?
Case Report (n=1)
Does retrograde venography to navigate an occluded subclavian vein facilitate cardiac resynchronization therapy upgrade via His bundle pacing in a patient with pacing-induced cardiomyopathy?
Retrograde venography from femoral access can identify collateral veins to facilitate direct percutaneous puncture and successful CRT upgrade via His bundle pacing in patients with subclavian vein occlusion.
May enable CRT access in subclavian occlusion; leaves open whether His bundle pacing upgrades improve outcomes in pacing-induced cardiomyopathy.
Background: Guidelines support upgrade to cardiac resynchronization therapy (CRT) through His-bundle pacing (HBP) in pacing-induced cardiomyopathy and moderate left ventricular systolic dysfunction (LVSD). Lead-related venous occlusion can represent an obstacle to upgrade procedures. We describe a technique to overcome venous occlusion through direct puncture of a collateral vein facilitating upgrade to HBP. Case summary: An 84-year-old man with a right ventricular (RV) pacemaker was referred with New York Heart Association (NYHA) Class III breathlessness secondary to moderate LVSD (left ventricular ejection fraction [LVEF] 45%). Device interrogation revealed 100% RV pacing and AV-dyssynchrony. To optimize atrioventricular (AV) and interventricular (VV) synchrony a CRT upgrade with HBP was planned. Venography revealed an occluded left subclavian vein which was probed in a retrograde manner using a 6F MPA catheter from right femoral venous access. We were able to direct the catheter distal to the left brachio-cephalic vein and define the occlusion using contrast. A collateral branch was identified, a J-wire was left in this branch and venous access was secured at this medial subclavian site using the Seldinger technique. A right atrial lead was deployed and 69 cm ISI-1 His lead was deployed via a C315 sheath at the His-bundle. The resulted in non-selective HBP (Stim-QRS end 146 ms). There were no procedural complications. Two months later both symptoms and LV function (LVEF 55%) improved. Discussion: Lead-related venous occlusion occurs frequently and can be probed in a retrograde manner from femoral venous access using contrast, facilitating direct percutaneous puncture of collateral venous branches to allow upgrade to CRT via HBP.
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Pavitt et al. (2023) conducted a case report in Pacing-induced cardiomyopathy with moderate LVSD and lead-related venous occlusion (n=1). Retrograde venography to facilitate direct puncture of a collateral vein for CRT upgrade via His bundle pacing was evaluated on Procedural success and clinical improvement. Retrograde venography facilitated direct puncture of a collateral vein to overcome subclavian occlusion, allowing successful CRT upgrade via His bundle pacing and LVEF improvement to 55% at 2 months.
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