Right Ventricular Outflow Tract Septal Pacing in Hue Central Hospital

Transcription

1 Right Ventricular Outflow Tract Septal Pacing in Hue Central Hospital Huỳnh Văn Minh Nguyễn Cửu Lợi Tô Hưng Thụy 1

2 Introduction Apical pacing has been introduced over the past 5 decades to save and improve Qo millions of lives presenting with bradycardia. Good things: easy do to, reliable pacing Bad things: LBBB, electrical and mechanical dyssynchrony LV dysfunction, CHF 2

3 Introduction Requirements of alternate sites of RV apical pacing: satisfactory favorable arguments Easy to implant, not much time-consuming and not expensive. Satisfactory the pacing parameters Better hemodynamic affects or at least not worse than that of apical pacing 3

4 Introduction Septal pacing & RV outflow tract septal pacing Since Jan 2010 RVOT septal pacing applied in Hue CVC using post. fashioned stylet This study s aims: 1. Assessing success rate, complications, implant time, radiation time 2. Pacing numbers at implant and 1 month 3. Paced QRS duaration and ECG features 4

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6 Clinical Studies of the Adverse Effects of RV Apical Pacing Trial No. of Pts Mean Age (y) Mean FU (y) LA Diameter LV Function CHF DAVID NA NA NA MADIT II sub Thackray et al NA NA NA NA NA MOST 1, NA NA Nielsen et al. O'Keefe et al NA NA NA NA AF 6

7 RVOT septum 7

8 RVOT Septum Conus arteriosus Supraventricular crest Septoparietal trabeculations Septomarginal trabeculation Moderator Band 9

9 Right Ventricular Outflow Tract F S A 10

10 Posterior angulation 11

11 Right Ventricular Outflow Tract Infundibulum RAO PA 12

12 Lead Implantation M P1,2 13

13 LAO RV LV Septum LAO 14

14 LAO 40º score 15

15 Methods Study population: 50 pts with indications for single or dual-chamber pacemaker were consecutive RVOT septal implants at the Hue Cardiovascular Centre between Jan 2010 and July 2010 Mean age: 71 ± 15.3 ( range 7-84 years), in which 17 females và 18 males Control group: 50 pts apical paced 16

16 Results: Our success rate: 100 % implanted to RVOT septum successfully. Stylet shape Swan Neck Use a Curved Stylet success rate 61% Vlay SC PACE 1998; 21:

17 1 curved without post angulation 150 Curved Stylet Insertions - RVOT Results: 61% (81 cases) septal LAO 40 o 39% (51 cases) anterior/free wall LAO 40 o McGavigan, Huế Cardiovascular Mond Centre PACE Oct

18 Catheter Delivery System Steerable Catheter - Medtronic SelectSite TM 4.1 Fr Medtronic 3830 SelectSecureTM 19

19 Passes Study 15 Au and NZ centres Success at RV septal placement Implanter Adjudicator 64 SelectSecure 62 Stylet 89% 89% 52% 60% O Donnell Huế Cardiovascular et Centre al. Europace 2008; 10: 20 i22

20 Complications No complication: no pneumothorax - cephalic vein access: 47/50 (94 %) No perforation, pericardial effusion No deaths related to PM complications No lead dislodgements, no diaphragmatic pacing, high pacing thresholds, or sensing issues. 21

21 Time to implant the V lead to RVOT septum Time for V lead Duration (seconds) Radiation time (seconds) to cross tricuspid valve up to Pulm. artery Pulled back and fixed to RVOT septum Total 12 ± 18,6 10 ± 4,8 21 ± 21,8 10 ± 14,4 7 ± 3,7 17 ± 16,9 22

22 LAO score result LAO score No. of cases Percentage 0 14 % 22% 64% { 86% } 23

23 Sufficient Sensing and Impedance Sensing (V) Impedance (Ohm)e Medtronic ,6 7,0 743,2±261,6 Tendril 1688 TC 13,2 ± 5,2 714,9±76,7 p value 0,85 0,11 24

24 Good Threshold in the lab All Medtronic 5076 Tendril 1688 TC Threshold 0 1,077 ± 0,34 0,98 ± 0,34 1,13 ± 0,34 Threshold 15 0,638 ± 0,17 0,58 ± 0,18 0,67 ± 0,15 P value < 0,0001 0,0007 0,0001 RVOT septum Apex P value Threshold 0,638 ± 0,17 0,425 ± 0,15 P <

25 Follow up of Threshold Thresold 0 Threshold 15 Threshold 24 h Threshold 1M Medtronic 0.98 ± ± ± ± Tendril ± ± ± ± 0.16 TC Means P value Lead Medtronic Tendril 1688 TC/ Thres0 Thres15 Thres24 Thres1M 26

26 ECG from RV apical pacing 27

27 ECG from RVOT septal pacing 28

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29 Paced QRS duration Intrinsic QRS < 100 ms Intrinsic QRS 100ms Average ms Paced beat width ± 7, ± ± 10.5 p 0.15 Intrinsic QRS ms Paced QRS ms Apex RVOT sep Apex RVOT sep 101 ± 25,7 103 ± ± ± 10.5 P > 0.1 P <

30 Other studies results Harry Mond và cs.:134 ± 21 ms (RVOTsep) Liverpool H Sydney: 139,8 ± 22,6 ms Paced QRS duration 190 ms a significant increase in the morbidity of CHF (P < 0.05) FUMITO MIYOSHI PACE Volume 28, Issue 11, November 2005 pqrsd 200 ms had sensitivity of 71.72% and specificity of to detect LVS Pan Wu J Card Fail May;15(4):

31 ECG characteristics Number of Patients Percentage % Negative in DI avl more neg than avr Transition V Transition V

32 Conclusions 1.RVOT septal pacing can be easily and reliably achieved with simple posteriorly fashioned conventional stylet. 2.Satisfactory pacing parameters with RVOT septal pacing 3.Paced QRS width is narrower than apical pacing with ECG patterns mimics normal activation. 33

33 Thank you for your attention! 34

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35 Normal Wave of Depolarization Work of Durrer (1970), 7 Subjects cerebral death - within 30 min recorded electrical activity (> 800 electrodes) Normal AV conduction - node to ventricle by His Purkinje < 55ms with simultaneous activation of IV septum and lateral wall. Base to apex. Narrow QRS with inferior axis 36

36 Right Ventricular Outflow Tract Infundibulum RAO PA 37

37 RVOT Septum Heart 022 The Visible Heart TM Medtronic 39

38 LAO 40 0 differentiate septal from free and anterior wall LAO 40 o Septum LAO 40 o Anterior wall LAO 40 o Free Wall 41

39 How do we to Achieve Alternative Site Pacing? The general belief is that standard screw-in leads can get to the RVOT, but not reliably onto the septum 42

40 ECG Apex F Apex VVI Apex Apex RVOT Septum 43

41 Septum F VVI Free Wall 44

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43 Right Ventricular Outflow Tract Infundibulum RAO PA 46

44 ECG characteristics Neg in DI Notch in II,III, avf Pos in avl avr more neg than avl avl more neg than avr Transi tion V4 Transi tion V5 No of Pts Percen tage % ,14 14,29 8,57 8,57 82, ,29 47

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