title: Direct left ventricular endocardial pacing: an alternative when traditional resynchronization via coronary sinus is not feasible or effective.
abstract: BACKGROUND
  Biventricular pacing through the coronary sinus (CS) is effective for the treatment of patients with heart failure and left bundle-branch block. However, this approach is not always feasible. Although surgical epicardial lead implantation is an alternative, the technique may be deleterious in some patients. Thus, direct left ventricular (LV) endocardial pacing under local anesthesia may be an option.
  
  
  OBJECTIVE
  We describe our technique and analyze the results of direct LV endocardial pacing.
  
  
  METHODS
  Fourteen patients with failed resynchronization via CS (April 2006-September 2011) were selected. Using a femoral approach, we performed transseptal puncture and LV mapping, then fixed the active lead where the longest electrical delay was observed; the generator was placed in the anterior thigh. For resynchronization, eight patients with a device previously implanted through the upper veins received a single-chamber generator that was set to the VVT mode to sense the subclavian pacing spike. Six patients received a complete femoral resynchronization system with either a defibrillator or pacemaker. Patients were followed for 6-54 months.
  
  
  RESULTS
  The LV lead was successfully implanted in all cases. Two patients experienced excessive bleeding and two died during follow-up. All except one improved at least one New York Heart Association class and experienced improved left ventricle ejection fraction. One patient with recurrent episodes of ventricular fibrillation was asymptomatic.
  
  
  CONCLUSIONS
  Direct LV endocardial pacing is safe and may be a less risky, more efficient alternative than surgical epicardial lead implantation for resynchronization via CS.
authors.affiliation: Pacing and Arrhythmia Department, Juan Ramón Jiménez Hospital, Huelva, Spain. pmorina@gmail.com
authors.forename: Pablo
authors.initials: P
authors.lastname: Moriña-Vázquez
authors.forename: Jessica
authors.initials: J
authors.lastname: Roa-Garrido
authors.forename: Juan M
authors.initials: JM
authors.lastname: Fernández-Gómez
authors.forename: José
authors.initials: J
authors.lastname: Venegas-Gamero
authors.forename: Rafael B
authors.initials: RB
authors.lastname: Pichardo
authors.forename: Manuel H
authors.initials: MH
authors.lastname: Carranza
mesh_terms: D000368:Aged; D002037:Bundle-Branch Block / Q000150:complications* / Q000175:diagnosis / Q000517:prevention & control*; D058406:Cardiac Resynchronization Therapy / Q000379:methods*; D058409:Cardiac Resynchronization Therapy Devices; D005240:Feasibility Studies; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017211:Treatment Failure