title: Percutaneous Epicardial Pacing using a Novel Insulated Multi-electrode Lead.
abstract: BACKGROUND
  Epicardial cardiac resynchronization therapy (CRT) permits unrestricted electrode positioning. However, this requires surgical placement of device leads and the risk of unwanted phrenic nerve stimulation. We hypothesized that shielded electrodes can capture myocardium without extracardiac stimulation.
  
  
  METHODS
  In 6 dog and 5 swine experiments, we used a percutaneous approach to access the epicardial surface of the heart, and deploy novel leads housing multiple electrodes with selective insulation. Bipolar pacing thresholds at prespecified sites were tested compare electrode threshold data both facing towards and away from the epicardial surface.
  
  
  RESULTS
  In 151 paired electrode recordings (70 in 6 dogs; 81 in 5 swine), thresholds facing myocardium were lower than facing away (median [IQR] mA: dogs 0.9 [0.4-1.6] vs 4.6 [2.1 to >10], p<0.0001; swine 0.5 [0.2-1] vs 2.5 [0.5-6.8], p<0.0001). Myocardial capture was feasible without extracardiac stimulation at all tested sites, with mean ± SE threshold margin 3.6±0.7 mA at sites of high output extracardiac stimulation (p=0.004).
  
  
  CONCLUSIONS
  Selective electrode insulation confers directional pacing to a multielectrode epicardial pacing lead. This device has the potential for a novel percutaneous epicardial resynchronization therapy that permits placement at an optimal pacing site, irrespective of the anatomy of the coronary veins or phrenic nerves.
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Faisal F
authors.initials: FF
authors.lastname: Syed
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Christopher V
authors.initials: CV
authors.lastname: DeSimone
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Elisa
authors.initials: E
authors.lastname: Ebrille
authors.affiliation: Mayo Medical School, Mayo Clinic, Rochester, MN.
authors.forename: Prakriti
authors.initials: P
authors.lastname: Gaba
authors.affiliation: Mayo Clinic Ventures, Mayo Clinic, Rochester, MN.
authors.forename: Dorothy J
authors.initials: DJ
authors.lastname: Ladewig
authors.affiliation: Mayo Clinic Ventures, Mayo Clinic, Rochester, MN.
authors.forename: Susan B
authors.initials: SB
authors.lastname: Mikell
authors.affiliation: Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Scott H
authors.initials: SH
authors.lastname: Suddendorf
authors.affiliation: Mayo Clinic Ventures, Mayo Clinic, Rochester, MN.
authors.forename: Emily J
authors.initials: EJ
authors.lastname: Gilles
authors.affiliation: Mayo Clinic Ventures, Mayo Clinic, Rochester, MN.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Danielsen
authors.affiliation: ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic.
authors.forename: Markéta
authors.initials: M
authors.lastname: Lukášová
authors.affiliation: ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic.
authors.forename: Jiří
authors.initials: J
authors.lastname: Wolf
authors.affiliation: ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic.
authors.forename: Pavel
authors.initials: P
authors.lastname: Leinveber
authors.affiliation: ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic.
authors.forename: Miroslav
authors.initials: M
authors.lastname: Novák
authors.affiliation: ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic.
authors.forename: Zdeněk
authors.initials: Z
authors.lastname: Stárek
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN; ICRC - Department of Cardiovascular Diseases, St Anne's University Hospital, Brno, Czech Republic.
authors.forename: Tomas
authors.initials: T
authors.lastname: Kara
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Bruce
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Friedman
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota.
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Asirvatham
keywords: Biventricular pacing; bioelectrical therapy; cardiac resynchronization therapy; epicardial mapping; epicardial pacing; minimally invasive; multisite pacing; pericardial intervention; phrenic nerve stimulation; steerable pericardial sheath