Left ventricular guidewire pacing for transcatheter aortic valve. implantation
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1 Page 1 of 8 Left ventricular guidewire pacing for transcatheter aortic valve implantation Ênio E. Guérios, MD 1, 2, Peter Wenaweser, MD 1, Bernhard Meier, MD 1 1 Department of Cardiology, Bern University Hospital, Bern, Switzerland 2 Concept Centro de Cardiopatias Congênitas e Estruturais do Paraná, Curitiba, Brazil Indexing words: cardiac pacing, aortic stenosis, balloon valvuloplasty Short title: Left ventricular wire pacing for TAVI Correspondence: Bernhard Meier MD, Professor and Chairman of Cardiology, Bern University Hospital 3010 Bern, Switzerland bernhard.meier@insel.ch Phone: Fax: This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as an Accepted Article, doi: /ccd.24474
2 Page 2 of 8 Abstract Previous reports prove the safety and efficacy of cardiac pacing employing a guidewire in the left ventricle as unipolar pacing electrode. We describe the use of left ventricular guidewire pacing as an alternative to conventional transvenous temporary right ventricular pacing in the context of transcatheter aortic valve implantation. 2
3 Page 3 of 8 Introduction Rapid cardiac pacing at rates of beats per minute is an effective technique for balloon stabilization during aortic balloon valvuloplasty or transcatheter aortic valve implantation (TAVI). The traditional way of temporary pacing involves a femoral or jugular venous puncture to place a pacemaker lead in right ventricle. However, effective cardiac pacing can also be accomplished using most guidewires as unipolar electrode in the left ventricle [1]. Exceptions are fully coated guidewires. We describe a case of a patient with permanent pacemaker in whom aortic balloon valvuloplasty prior to TAVI was done under left ventricular rapid pacing via the extra-stiff wire used for valve implantation. Case Report A 79-year-old male patient with 3-vessel coronary artery disease, severe aortic stenosis (valve area= 0.4cm 2, mean gradient=60mmhg), paroxysmal atrial fibrillation and total atrioventricular (AV) block was referred for treatment of acute decompensated heart failure. Six days after insertion of a VVI pacemaker (Reply SR, Sorin Group, Milan, Italy) and percutaneous coronary intervention (PCI) with stenting of the left anterior descending and the right coronary arteries, the patient underwent TAVI. After crossing the stenotic aortic valve with an Amplatz AL1 5F catheter, an Amplatz extra-stiff guidewire (Cook Inc., Bloomington, IN, USA) with a custom-shaped pigtail tip was placed in the left ventricle. As the patient already had a permanent pacemaker protecting against bradycardia during and after valve implantation, the brief rapid pacing required for valve placement was accomplished over the guidewire in the left ventricle according to previous reports on guidewires employed for temporary pacing [1-4]. The external end of the Amplatz wire was connected to the cathode (negative pole) of a single chamber Medtronic 5348 temporary pacemaker (Medtronic Inc., Minneapolis, MN, USA) with an alligator clamp, whereas the anode (positive pole) was connected to a large surface skin electrode at the left thigh of the patient. Pacing was instituted at 180 beats per minute, with output set at maximum and sensitivity turned off. It decreased the mean arterial pressure to about 60mmHg and the 3
4 Page 4 of 8 pulse wave to around 10mmHg. Balloon valvuloplasty with a 22x40mm balloon could be safely performed (fig. 1). A 31mm CoreValve Bioprosthesis (Medtronic Co, Irvine, CA, USA) was then implanted, leading to a reduction of the mean transvalvular gradient from 60mmHg to 9mmHg. For a moderate residual aortic regurgitation observed after valve implantation, a post-dilation of the valve was performed with a 50x20mm balloon, again under rapid pacing with the left ventricular guidewire, resulting in a final mild aortic regurgitation. Due to paroxysmal atrial fibrillation, a CHA 2 DS 2 -VASc score of 4, and the inherent bleeding risk of triple therapy with warfarin, clopidogrel, and acetylsalycilic acid, the patient s left atrial appendage was occluded with an Amplatzer Cardiac Plug 22mm (St. Jude-AGA, Plymouth, MN, USA) at the end of the procedure. The further course was uneventful. Discussion Coronary [2] and left ventricular [3] pacing during PCI have been proved safe and effective as an alternative to classic transvenous right ventricular pacing. The technique has been described as a way to simplify pediatric aortic balloon valvuloplasty [1]. This is a first description of the technique in the context of TAVI. This approach obviates the need for an additional venous puncture and avoids cost, discomfort, and the small risk of creating an arteriovenous fistula at entry site or of perforating the right ventricle with a temporary pacemaker lead. Moreover, in this particular patient mechanical interference with a recently implanted permanent pacemaker was avoided. It should be noted that rapid pacing by temporally reprogramming the permanent pacemaker would have been an alternative, albeit somewhat complicated and dependent on the pacemaker model. The requirements for effective left ventricular guidewire pacing are wire insulation provided by the balloon, good contact between wire and ventricular endocardium, and the correct assembly of the stimulation system [4]. The wire should be used as a cathode and the skin electrode as an anode to obtain the lowest possible threshold. The alligator clamp has to be clipped to the noninsulated end of the guidewire. Alternatives to the skin electrode at the thigh used in this case are a skin electrode at the trunk or a needle in the anesthesized 4
5 Page 5 of 8 groin area [5]. Attention must be given to the fact that if the wire looses contact with the endocardium pacing may stutter. These details observed, left ventricular wire pacing can be a useful adjunctive technique in the setting of TAVI. When using a CoreValve it can be used during balloon inflation before and if required after valve implantation. When using an Edwards-Sapien valve, it is also used during the actual valve implantation. With a Corevalve, its feasibility may be limited to patients with a permanent pacemaker (as in the case reported here) in light of the substantial risk of protracted or permanent pacemaker dependency due to total AV block. With an Edwards-Sapien valve (much lower respective risk), it may become standard of care. Conclusion Left ventricular guidewire pacing is effective and easily accomplished. It can be considered as a reliable alternative to conventional transvenous temporary right ventricular pacing in the context of transcatheter aortic valve implantation. 5
6 Page 6 of 8 References 1. Navarini S, Pfammatter J-P, Meier B. Left ventricular guidewire pacing to simplify aortic balloon valvuloplasty. Cathet Cardiovasc Interv 2009; 73: Meier B, Rutishauser W. Coronary pacing during percutaneous transluminal coronary angioplasty. Circulation 1985; 71: de la Serna F, Meier B, Pande AK, Urban P, Adatte JJ, Moles VP, Killisch JP, BodenmannJJ, Barcellona G, Dorsaz PA. Coronary and left ventricular pacing as standby in invasive cardiology. Cathet Cardiovasc Diagn 1992; 25: Meier B. Emergency pacing during cardiac catheterization: it is all there already. Cathet Cardiovasc Interv 2004; 61: Mixon TA, Cross DS, Lawrence ME, Gantt DS, Dehmer GJ. Temporary coronary guidewire pacing during percutaneous coronary intervention. Cathet Cardiovasc Interv 2004; 61:
7 Page 7 of 8 Figure legend Figure 1: Left: Balloon inflation during rapid pacing achieved via the guidewire touching the left ventricle (arrow). The arrow head depicts the permanent pacemaker lead. S = coronary stent. Right: aortic phasic and mean pressure curves during and immediately after left ventricular pacing using the guidewire. 7
8 Page 8 of 8 Figure 1 23x13mm (300 x 300 DPI)
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