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A modified snare technique improves left ventricular lead implant success and response rate to cardiac resynchronization therapy
Session:
Sessão de Comunicações Orais - Dispositivos Médicos
Speaker:
Afonso Nunes Ferreira
Congress:
CPC 2020
Topic:
C. Arrhythmias and Device Therapy
Theme:
09. Device Therapy
Subtheme:
09.3 Cardiac Resynchronization Therapy
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Afonso Nunes Ferreira; Pedro Silvério António; Inês Aguiar Ricardo; Tiago Graça Rodrigues; Joana Rigueira; Rafael Santos; Nelson P. Cunha; Sara Couto Pereira; Mafalda Carrington; Ana Bernardes; Fausto José Pinto; João Rodrigues De Sousa; Pedro Nuno Carlos Marques
Abstract
<p>Introduction:<br /> Left ventricular (LV) lead placement is often the most challenging aspect of cardiac resynchronization therapy (CRT) device implantation, with a failure rate up to 10% due to complex coronary anatomies.</p> <p>Purpose:<br /> To evaluate the efficacy of a modified snare technique in the LV lead implantation in cases of standard technique failure and to evaluate its impact in the response rate to CRT.</p> <p>Methods:<br /> A prospective study was conducted of patients (pts) indicated for a CRT implant. When LV lead delivery to the target vessel failed using standard techniques, a modified snare technique was implemented. Pts were evaluated every 6 months. Efficacy was quantified by long-term surgical intervention rates. Pts were evaluated with transthoracic echocardiography before CRT implant and between 6-12 months post-implant. Pts with ejection fraction (EF) elevation ≥ 10% or LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Pts with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Analysis with Cox regression and Kaplan-Meier methods.</p> <p>Results:<br /> From 2015-2019, 566 CRTs were implanted (26.1% female, 72±10.2 years old, follow-up 18.9±15.8 months). Standard LV implant technique failed in 94 cases (16.6%), of which the modified snare technique was successful in 97.9% with LV lead implant in a lateral vein in 94.7% of cases. Baseline clinical characteristics were similar between patients who implanted LV lead with snare vs standard technique. The 4-year surgical intervention rate was lower with the modified snare implant technique than with the standard technique (3.2% vs. 10.2%, HR 0.26, 95% CI 0.08-0.84, p<0.05), with a risk reduction of 74% and a number needed to treat of 14. Major complications were similar between groups.<br /> The response rate to CRT was higher in the modified snare technique than in the standard approach (71.1% vs 55.0%, p<0.05). In patients who implanted the LV lead with the snare technique, EF increased from 28.1 ± 8.2% to 36.1 ± 11.1% (p<0.05) and LV ESV decreased from 127.8 ± 64.0mL to 99.8 ± 61.1mL (p=0.01).<br /> The super-response rate was similar between groups (33.3% vs 27.8%, p=NS).</p> <p>Conclusion:<br /> For challenging coronary sinus anatomies that preclude LV lead placement by standard methods, modified snare alternative was effective, with lower surgical intervention rates and higher response rate to resynchronization therapy, probably due to the implant of LV lead in the target lateral vein.</p>
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