CRT Case-Based Troubleshooting

1. CRT Case-Based Troubleshooting
黃金隆
台中榮總
心臟血管中心
THRS CIED PHYSICIAN TRAINING
COURSE

2. Troubleshooting
• CS: Inability to engage, dissecting.
• Extra-cardiac stimulation: PNS.
• Pacing failure.
• Inadequate bi-ventricular pacing.
• Upgrade to CRT-right side approach.
• SVT vs VT
• Responders.

3. Inability to engage, dissecting

4. Anatomy of CSAnatomy of CS
RAO
AP
LAO

5.  Steep LAO: 400
 Left sided implants:
 Operator should stand
on right side

6. EP GuideEP Guide

7. Where is the orifice of CS

8. Tricuspid Annulus & CS OrificeTricuspid Annulus & CS Orifice

9. AP view + EP electrograms of CS

10. AP view + EP electrograms of CS in AF

11. CRT implantation-
How to engage CS by EP catheter

12. Case 1
 A 63 yr man was a case of dilated
cardiomyopathy with VT and wide QRS
duration and low LVEF= 20 %.
 He was suggested to receive cardiac
resynchronization therapy to improve his
heart failure.

13. CRT implantation-
CS engagement by EP catheter

14. CS angiography
Acute angle of LCV

15. How to do it ?
Subselective catheter

16. CS dissecting
How to manage this situation ??

17. Final position of LV lead

18. CS Dissection
 Contak CD study: perforation or dissection
of the coronary sinus in 1.8% and extra
cardiac stimulation of 1.6%.
 Management:
 Surgical approach
 Delay the LV lead implantation after 2 weeks
 Select another cardiac vein

19. Repeat venography after
CS dissection
Antero-lateral cardiac vein

20. Final Position of LV lead
(RAO 200
)

21. PNS not found during the implantation
but occurred during OPD F/U ??

22. PS implications in CRT
Author
(year)
Cathode
programmabi
lity
Intra-
operative
LV lead
repositioni
ng
PS at f/u
LV lead
replaceme
nt
PS-
related
CRT
failure
Gurcwitz et al. (2005) 47% NA 11% 13% 2%
Cathode
programmbility
100% NA 9% 0% 0%
No cathode
programability
0% NA 16% 24% 4%
Biffi et al. (2009) 29% 3%
24% (14%
symptomatic)
5% 2%
Cathode
programmbility
100% 0%
13% (10%
symptomatic)
0% 0%
No cathode
programability
0% 9%
28% (18%
symptomatic)
7% 3%
Seifert et al. (2010) 30% 10% 33% (9% symptomatic) 1% 0%

23. Incidence of PNS in different locationsIncidence of PNS in different locations
PNS frequently
at middle–
lateral/posterior
,
apical LV sites
Biffi et al. Europace. 2012 Jul 29

24. Supine Left lateral Sitting
Phrenicthreshold
(V@0.4ms)
4.43±0.9 3.51±1.2 4.07±1.9
LVthreshold
(V@0.4ms)
1.07±0.6 1.09±0.5 1.11±0.6
Seifert et al : PS 0.9 V lower in left lateral vs supine at FU
LV pacing : TIP to RV Coil/ring

25. 70% of PS-related lead repositionings occurred at this site
Seifert et al. Europace (2010) 12, 961–967

28. To AVOID SEVERE ISSUES
≥ 3V IS NEEDED atA PS-LV safety margin
long term because of
- LV THRESHOLD FLUCTUATIONS
- PS THRESHOLD POSTURAL CHANGES

29. Guidewire method

30. Case 1
 EP catheter guide engagement
 CS dissecting during acute angle.
 PTCA wiring to find new route
 Post implantation PNS could be managed
by the change of vector.
 Multi-electrode LV lead provided multiple
choices.

31. 中央健保局
植入心臟再同 化節律器的相關規定步 (98.07.01)
• ( 一 ) 應事先審 。查
• ( 二 ) 正常竇房節心律，左心室搏出分率≦ 35% ，且左
側支束傳導完全阻滯， QRS 波的 度≧寬 120 毫秒，紐
約心臟學會功能分級是第三級或者第四級經適當藥物治療
仍不能改善之病患。
• ( 三 ) 心房顫動之病患，左心室搏出分率≦ 35% ，且左
側支束傳導完全阻滯， QRS 波的 度≧寬 120 毫秒，紐
約心臟學會功能分級是第三級或者第四級經適當藥物治療
仍不能改善之病患。
• ( 四 ) 心室節律器依賴之病患，左心室搏出分率≦
35% ，紐約心臟學會功能分級是第三級或者第四級經適當
藥物治療仍不能改善之病患。

32. Case 2
• A 84 yr male patient is a case of DCM,AF
CLBBB, CHF Fc IV
• Frequent admission due to pul edema and
rapid atrial fibrillation.
• CRT-P implantation.

33. Class IIa: AF + CHF
1.Is it necessary to implant RA lead?
2.Routine AV node ablation ?

34. CHF + Chronic AF

35. CHF + Chronic AF
(Mrs. Chang CJ)
2008.01.15 2009.11.13

36. Chronic AF

37. 2 years later
How can we do if no RA lead ?

38. Spontaneous conversion to SR
(2010.02.26)

39. Transient turn-off the CRT
RA lead in chronic AF

40. Case 3
• A 65-year-old woman: DCM,PAF +VT s/p
CRT-D on 2013/10/16, CHF Fc IV LVEF:
14%.
• Peri-procedure complication .
• Rapid atrial fibrillation

41. Pre- CRT

42. Cardiomegaly

43. CS engagement
What will happen ?

44. CS Dissecting
Initial slow injection/test dose is suggested!

45. Guide-wire approach
0.014 PTCA wiring !

46. LV lead

47. After CRT-D

49. Poor Bi-ven during
rapid AF

50. Low Bi-ventricular pacing rate %

51. Bi-ven after
medication

52. Case 2,3
• RA lead is suggested in chronic AF.
• Initial test injection is prefered
• PTCA wire during the CS dissecting
• Rate control is necessary during rapid AF.

53. Effect of CRT on conversion of
persistent AF to sinus rhythm.
Becher et al. Clin Res Cardiol. 2009 ;98(3):189-94
• 46 with persistent AF (> or =4 wks pre-implant), QRS >
130 ms, LVEF <0.35, NYHA III or IV heart failure.
• During 22 +/- 9 (7-34) ms of follow-up, 8 out of 46
patients (17%) converted to SR.
• Echo: LVEF,LA diameter did not differ significantly
• Pts converting to SR showed a significant reduction in
systolic PA pressure on CRT vs. before CRT (45 +/-
13 vs. 29 +/- 5 mmHg, P = 0.008).
RA lead is necessary !!

54. Does AF preclude biventricular pacing?
AF/SR No. of AF patients
with AVN ablation
FU Echo and
clinical
benefit by
CRT
Favourable
outcome in
AF patients
with AVN
ablation
Molhoek 30/30 17(57%) before CRT 25m AF=SR No
difference
Delnoy 96/167 21(22%), only 2 with
pacing <50% after
CRT
22.9m AF=SR Not
mentioned
Leclercq 15/22 15(100%) 14.4m AF=SR Not
applicable
Gasparini 162/349 114(70%) if pacing
<85%
34m AF+AVN=SR Yes
Khadjooi 86/209 0 81.6 AF=SR Not
applicable
Fung JW. Heart 2008 94(7):826-7. It is not necessary to do the
routine AV node ablation.

55. Class IIa: CHF + Pacing
dependent
1.Pre-existing PPM.
2.How to tx the venous occlusion?

56. A
B
Case 4. Cardiac sarcoidosis with AV block s/p VVI

57. A
B
Su, Huang et al. Sinica
Cardiologica 2009

58. The tough thing while upgrading
from pacemaker to CRT ?

59. Occlusion of SCV

60. Epicardial approach (n=5) Right side approach (n=26)
Epicardial approach needs general anesthesia
and recovery time

61. Guidewire method

62. Case 5: Upgrade of PPM to CRT

63. Case 4,5
 Upgrade from PPM to CRT
 Opposite site approach is preferred
 Guidewire method is prefered

64. Case 6
 Name: Wang XX
 Age: 89 year-old
 Sex: Male
 BW: 64 kg: BH: 164 cm
 C.C.: Dyspnea on exertion, orthopnea
and PND for more than one year

65. Brief History (1)
 A 89-year-old man
 Ischemic cardiomyopathy, NYHA Fc III-IV, LVEF: 22%.
 CLBBB with QRS duration of 200 ms.
 Refractory to optimal medical treatment :
 Aspirin, Carvedilol, Fosinopril
 Underlying diseases:
 CAD-I (LAD) s/p POBA + BMS in 2009
 HCVD
 Type 2 DM
 PAOD, s/p PTA
 Chronic renal insufficiency

66. CXR
Mar. 22, 2010
•Cardiomegaly
•Interstitial edema
•Pleural effusion

67. ECG
NSR, CLBBB, QRS duration : 200 ms

68. CRT Implantation May 27th ,2010-
CS Venogram
Big Target vein

69. Which lead is prefered

70. CRT Implantation-
leads Positioned over RV, LV (4194 6F) and RA
May 27, 2010
LAO 60° AP view

71. ECG s/p CRTECG s/p CRT
NSR, Bi-V pacing with narrow QRS

72. May 27 s/p CRT
May 31
Baseline
What happen ??

73. CXR
Dislodgement of LV
lead to RA
May 27 May 31

74. LV lead re-implantation
Procedure:
 Not necessary to do
another needle
venopucture, just
 Re-introducing a PTCA
wire over the LV lead
 Retrieve the LV lead
 Re-advancing a long
sheath and engage to CS
 Re-implant LV lead to
LCV.
Jun 01,2010
0.014"
guide wire

75. Changing a new Lead, Starfix lead
in the same branch

76. ECG post LV lead re-implantationECG post LV lead re-implantation
NSR, Bi-V pacing with narrow QRS

77. It is useful to fix the LV lead in the
target vein by Starfix lead

78. an active-
fixation LV lead
(4195 unipolar)
showed a
15.3% PNS
occurrence at
follow-up.
Biffi et al. Europace. 2012 Jul 29

79. Larger diameter lead to match lead-
vein diameter ?

80. Case 7
 Name: Mr. Lee
 Age: 74 year-old
 Sex: Male
 BW: 65 kg: BH: 172 cm
 C.C.: General weakness and dyspnea
for two weeks.

81. Brief History (1)
 A 74-year-old man
 Ischemic cardiomyopathy, NYHA Class IV,
LVEF: 26%
 CLBBB with QRS duration of 164 ms .
 Comorbidities:
 CAD-III s/p PCI with stenting.
 HCVD
 Type 2 DM
 Old pulmonary TB
 BPH
 COPD

82. ECG
Af, CLBBB, QRS:164 ms

83. CS Venography
Lat Marginal Cardiac
vein, but acute angle

84. LV lead position after CRTLV lead position after CRT
AP view LAO 600 view
Attain
Select® II
Suboptimal
position
LV lead dislodged 10 minutes after CRT

85. Redo CS Angiography
Another choice to
MCV

86. Starfix lead not available—
cannulate another branch-MCV

87. Case 6,7Case 6,7
 It is not all necessary to match lead-vein
size.
 Small caliber lead with deep insertion is
suggested.
 In the acute angle vein, try another cardiac
vein.

88. Case 8: Stable became unstable
 83-year-old woman : DCM, CHF NYHA Fc
IV, CLBBB and VT, s/p CRT-D on
2009/11/05, FC II-I –Good response.
 LVEF=30%- 62%

89. Good response

90. LVEF=62%LVEF=62%

91. SOB occurred

92. Lead status

93. Unstable OptiVol

94. Case 8
 Lead status should be monitored
periodically.
 Change from stable to unstable situation
implied something wrong.

95. Case 9: SVT vs VT

96. Sudden onsetSudden onset

97. SVT DxSVT Dx

98. Case 10
 A 60 yr male, DCM with CHF, NYHA Fc III
and Af with CLBBB, sudden collapse s/p
resuscitation S/P CRT-D implantation .
 Several episodes of shock
 Progressive dyspnea

99. Atrial under sensing
Where is the marker

100. Serial ECGSerial ECG
Amiodarone for PAF

101. Widen QRS during bi-v pacing

102. Widen QRS

103. Adjust the AV interval

104. AV Delay Optimization Methods
Too short AVToo short AV Too long AVToo long AV ““Just Right” AVJust Right” AV
E and A wavesE and A waves
separated,separated,
but A wave is truncatedbut A wave is truncated
E A
E and A wavesE and A waves
fused,fused,
but DFT reducedbut DFT reduced
E A
E
A
E and A wavesE and A waves
separatedseparated
and DFT mantainedand DFT mantained

105. Adjust the AV =350 msec

106. Case 9,10
 Differential dx of tachycardia from SVT vs
VT.
 Interrogation is necessary to evaluate the
lead status and local electrograms
 Individual optimization of AV interval.

107. Predicting
Response to CRT
Patient SelectionEvidence of
dyssynchrony
Adequate lead
placement
Atrial
fibrillation
Perisistent
mitral
regurgitation
Cardiac
ischemia
Prerenal
azotemia
Increased nonresponder rate

108. Huge
scar !!

109. Integration of Anatomical and
Functional Evaluation
JACC Cardiovasc Imaging. 2014 Dec;7(12):1239-48

110. Integration of Anatomical and
Functional Evaluation
Scar
burden
Latest
activation
Coronary
sinus
accessibility

111. Integration of Anatomical and
Functional Evaluation
Scar
burden
Latest
activation
Coronary
sinus
accessibility

112. Integration of Anatomical and
Functional Evaluation
Latest
activation
Coronary
sinus
accessibility
Scar
burden

113. Case 11
• A 53 yr male patients with DCM, CLBBB,
CHF Fc III with LVEF=30%.
• Medication for one year.
• Condition did not improved

114. LV sites selection

115. Early onset of electrical reverse remodeling

116. Conclusion
• CS: engaged by EP guide or guidewire
method, dissecting find another way.
• Extra-cardiac stimulation: PNS—multi-
electrode lead.
• Pacing failure: dislodge or scar
• Inadequate bi-ventricular pacing: rate
control esp in the rapid AF
• SVT vs VT differentiation
• Lead status

117. Thank you for your attention !!