Key result
Femoral access-guided subclavian sheath insertion for ICD+CRT achieves 99.8% complication-free CS access.
Why the study?
Multisite ICD (ICD+CRT) procedure times can be extended due to difficulties navigating to the coronary sinus.
Does femoral access-guided multi-site ICD implantation improve procedural success and time in patients with refractory HF, LBBB, and VT?
Cohort (n=903)
No
Does femoral access-guided multi-site ICD implantation improve procedural success and time in patients with refractory HF, LBBB, and VT?
Femoral access-guided multi-site ICD implantation is a highly successful and safe technique that reduces procedure time and radiation exposure.
Background Multisite Implantable Cardioverter-Defibrillator (ICD+CRT) therapy is the established treatment for patients with dilated cardiomyopathy, Left Bundle Branch Block (LBBB), and Ventricular Tachycardia (VT). However, procedure time can be extended due to difficulties navigating to the Coronary Sinus (CS). Objectives To present our extensive experience in 903 cases utilizing the femoral vein puncture as a guide to facilitate the subsequent approach and sheath insertion into the subclavian vein for CS lead placement. Methodology: Between March 2010 and August 2025, 903 patients received ICD+CRT implants. The cohort predominantly consisted of men (590 patients, 65%). These patients presented with refractory Heart Failure (HF), an Ejection Fraction (EF 35%), LBBB, and VT. In this series, the CS access was achieved via the femoral approach. Immediate success was defined by QRS narrowing; thus, all patients underwent femoral vein puncture and the introduction of a quadripolar catheter into the CS. This initial catheter served as a guide for the subsequent insertion of a second quadripolar catheter inside the sheath, easily directing it to the CS. This allowed for a venogram and the selection of the ideal vein for Left Ventricular (LV) electrode placement. Results The procedure was highly successful, with 99.8% of cases achieving CS access without major complications such as perforation, rupture, or tamponade. Clinically, 74% of patients experienced QRS complex narrowing, with a mean duration of 110ms. Late postoperative lead dislodgement of the LV electrode occurred in only four patients (0.44%), managed in a secondary procedure. Eight patients (0.88%) required implantation via the right subclavian vein, and four (0.44%) had a persistent Left Superior Vena Cava (LSVC). Immediate postoperative phrenic nerve stimulation occurred in 30 patients (3.32%), which was successfully managed by reprogramming pacing parameters. The average procedure time, from femoral puncture to pocket closure, ranged from 1 hour 20 minutes to 2 hours 30 minutes, with a mean of just 1h and 30 minutes. Conclusion The adoption of the femoral access technique to guide the subclavian sheath introduction effectively reduced the overall procedure time to a low average of 1h 30 minutes, consequently leading to a reduction in ionizing radiation exposure for both the patient and the clinical team.
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Filho et al. (2026) conducted a cohort in Refractory Heart Failure, Dilated Cardiomyopathy, LBBB, and VT (n=903). Femoral access-guided subclavian sheath introduction for coronary sinus lead placement was evaluated on Coronary sinus access without major complications. Femoral access-guided subclavian sheath introduction for ICD+CRT implantation achieved a 99.8% success rate for coronary sinus access with an average procedure time of 1 hour and 30 minutes.
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