Cardiac resynchronization (CRT) is a well-established treatment for heart failure and standard superior implantation has a high success rate with acceptable risk profile. When the superior approach is not feasible, surgical epicardial leads are considered. We present a case of transfemoral CRT as a viable alternative to surgical systems and discuss implant factors including lead choice and deep vein thrombosis.
Cardiac resynchronization (CRT) is a well-established treatment for heart failure. When the superior approach is not feasible, surgical epicardial leads are considered. We present a case of transfemoral CRT as a viable alternative to a surgical system in a 62-year old lady with heart failure and broad QRS but bilateral subclavian occlusion due to prior radiotherapy.
Infrainguinal right femoral vein access was achieved and 65 cm active-fixation leads sited in the right atrium and right ventricular (RV) apex. Coronary sinus cannulation required SL3 and sub-selector sheaths (AP projection in upper panel). Venography demonstrated a lateral target branch into which a passive left ventricular (LV) lead was sited. All leads were tunnelled over the inguinal ligament, secured to the rectus muscle in the right lower abdominal quadrant and connected to a CRT generator. Subsequent displacement of both ventricular leads necessitated revision with active-fixation 85 cm RV and Starfix LV leads (left anterior oblique projection in lower panel demonstrating final lead positions). The patient experienced symptomatic improvement and remains well 2 years post-implant.
Transfemoral CRT is a viable alternative to surgical epicardial systems when subclavian access is not feasible. Indications for transfemoral pacing include occluded subclavian veins or superior vena cava (SVC), multiple SVC leads, and pectoral tissue unsuitable for device burial.
The full-length version of this report can be viewed at: http://www.escardio.org/communities/EHRA/publications/ep-case-reports/Documents/The-transfemoral-approach.pdf.
