title: Development of a technique for left ventricular endocardial pacing via puncture of the interventricular septum.
abstract: BACKGROUND
  Left ventricular (LV) pacing through the coronary sinus is the standard approach for cardiac resynchronization therapy. When this route is unavailable, the alternatives have major limitations. LV endocardial pacing through the interventriuclar septum may offer a simpler solution. We describe an initial case series to demonstrate technical feasibility and to describe our refinement of the puncture technique.
  
  
  RESULTS
  Ten patients with previous failed coronary sinus lead implant or with nonresponse to cardiac resynchronization therapy and a suboptimal LV lead position were selected. All patients were anticoagulated. Left ventriculography and coronary angiography were performed to identify LV borders and septal vessels. Subclavian vein access was used for a superior approach ventricular transseptal puncture under fluoroscopic guidance, using a steerable sheath and a standard transseptal needle, radiofrequency needle, or radiofrequency energy delivered through a guidewire. An active-fixation pacing lead was successfully delivered to the endocardial wall of the lateral LV in all patients (9 men; age, 62±10 years). LV lead implant procedure time shortened with experience. The use of radiofrequency energy delivered through a guidewire was the most effective technique. Mean threshold and R wave at implant were 0.8±0.3 V and 10.8±3.9 mV. At follow-up (mean, 8.7 months; minimum, 0; and maximum 19), thresholds were stable, and there were no thromboembolic events. Of 9 patients, 8 were classed as clinical responders (1 had inadequate follow-up to assess response).
  
  
  CONCLUSIONS
  LV endocardial pacing through a ventricular septal puncture is a feasible approach for cardiac resynchronization therapy.
authors.affiliation: Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.
authors.forename: Tim R
authors.initials: TR
authors.lastname: Betts
authors.forename: James H P
authors.initials: JH
authors.lastname: Gamble
authors.forename: Raj
authors.initials: R
authors.lastname: Khiani
authors.forename: Yaver
authors.initials: Y
authors.lastname: Bashir
authors.forename: Kim
authors.initials: K
authors.lastname: Rajappan
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D006328:Cardiac Catheterization / Q000379:methods*; D058406:Cardiac Resynchronization Therapy / Q000379:methods*; D017023:Coronary Angiography; D004562:Electrocardiography; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011677:Punctures; D015641:Radiography, Interventional; D015635:Radionuclide Ventriculography; D013318:Stroke Volume; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D016277:Ventricular Function, Left; D054088:Ventricular Septum / Q000000981:diagnostic imaging; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: cardiac resynchronization therapy; endocardium; heart ventricles; septal