Case report
Cardiac resynchronization therapy: Femoral approach
Terapêutica de ressincronização ventricular: implantação por via femoral
Luís Brandão, Rita Miranda
, Sofia Almeida, Luciano Ribeiro, Carlos Alvarenga, Isabel João, Hélder Pereira
Corresponding author
Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
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] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917300922?idApp=UINPBA00004E" "url" => "/21742049/0000003600000004/v1_201704230025/S2174204917300922/v1_201704230025/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Cardiac resynchronization therapy: Femoral approach" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "309.e1" "paginaFinal" => "309.e3" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Luís Brandão, Rita Miranda, Sofia Almeida, Luciano Ribeiro, Carlos Alvarenga, Isabel João, Hélder Pereira" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Luís" "apellidos" => "Brandão" ] 1 => array:4 [ "nombre" => "Rita" "apellidos" => "Miranda" "email" => array:1 [ 0 => "ritasmiranda@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "Sofia" "apellidos" => "Almeida" ] 3 => array:2 [ "nombre" => "Luciano" "apellidos" => "Ribeiro" ] 4 => array:2 [ "nombre" => "Carlos" "apellidos" => "Alvarenga" ] 5 => array:2 [ "nombre" => "Isabel" "apellidos" => "João" ] 6 => array:2 [ "nombre" => "Hélder" "apellidos" => "Pereira" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Terapêutica de ressincronização ventricular: implantação por via femoral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1208 "Ancho" => 1485 "Tamanyo" => 166178 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Left anterior oblique view of final lead positions in the right atrium, right ventricle, and the posterolateral branch of the coronary sinus.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">We describe the case of a 62-year-old female patient in whom a cardiac resynchronization (CRT) system was implanted via a femoral vein. She had a history of Hodgkin's lymphoma in 2001, complicated by superior vena cava syndrome, had undergone chemotherapy and radiotherapy, and was in remission since then. In 2006 she underwent percutaneous coronary intervention with left main coronary artery stenting due to complaints of angina. In 2010, she developed left bundle branch block, and myocardial scintigraphy revealed left ventricular ejection fraction (LVEF) of 40%, without ischemia. In 2014 she developed symptoms of heart failure. An attempt was made to optimize medical therapy on an outpatient basis, but her clinical condition deteriorated and in February 2015 she was admitted to the hospital with severe heart failure (New York Heart Association [NYHA] functional class IV). The echocardiogram showed an LVEF of 25%, moderate to severe mitral regurgitation, preserved right ventricular systolic function and moderate pulmonary hypertension. Levosimendan perfusion was instituted and drug therapy was titrated (although hypotension precluded achievement of reasonable doses of angiotensin-converting enzyme inhibitors and beta-blockers), with progressive improvement to NYHA class III. Repeat coronary angiography showed no residual coronary disease and implantation of a CRT system was proposed. An attempt to implant a CRT defibrillator was unsuccessful due to bilateral subclavian vein occlusion. Surgical implantation of an epicardial left ventricular lead was not undertaken due to the patient's frailty and the strong possibility of severe mediastinal fibrosis, increasing the risk of procedural morbidity. We proposed implantation of a CRT system via a femoral approach, which was accepted by the patient. Considerations of generator size and weight, the low probability of obtaining an effective defibrillation vector at the level of the femoral region, and the fact that the patient was hospitalized for advanced heart failure, led to the selection of a pacemaker system.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Two active fixation leads (85 cm Medtronic CapSureFix Novus<span class="elsevierStyleSup">®</span> 5076) were implanted via the right femoral vein using peel-away introducers and positioned in the right ventricular septum and right atrial roof. Acute thresholds were 0.6 V for the right ventricle and 2.0 V for the right atrium, with impedances of 520 and 600 Ω, respectively. The R wave was measured at 5.5 mV and the P wave at 2.6 mV. A coronary sinus sheath (57 cm Medtronic Attain Command<span class="elsevierStyleSup">®</span> with SureValve 6250VI-EHXL) was introduced over a deflectable electrophysiology catheter (Bard Dynamic XT) and advanced to the coronary sinus. Venography was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) and a posterolateral vein was selected for placement of an 88 cm Medtronic Attain Ability<span class="elsevierStyleSup">®</span> 4196 bipolar lead (<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2–4</a>). These leads, as well as the coronary sinus sheaths, were selected because of their longer length, as the patient's height was 174 cm. A femoral pocket was created in the upper leg. The three leads and the generator were fixed to the muscle under the aponeurosis, using silk sutures.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Fluoroscopy time was 16 minutes and the entire procedure took less than two hours. Recovery was complicated by a pocket hematoma related to early administration of enoxaparin, which required surgical drainage. The patient was kept under permanent oral anticoagulation with warfarin.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The first follow-up visit took place 40 days after implantation. Her condition had improved markedly, and she presented in NYHA class II. The pacing system was working properly. Pacing thresholds were 0.75 V for the right atrium, 1.0 V for the right ventricle and 0.625 V for the coronary sinus lead. The measured P wave was 4.1 mV and the R wave in the right ventricular lead was 4.8 mV. Impedances were 418, 437 and 418 Ω in the right atrium, right ventricle and coronary sinus, respectively. At the last follow-up visit, nine months after implantation, the thresholds remained stable (thresholds, sensing and impedances were 0.75 V/3.9 mV/456 Ω for the right atrium and 0.75 V/3.8m V/475 Ω for the right ventricle; threshold and impedance for the coronary sinus lead were 0.75 V and 470 Ω), and she is still in NYHA class II, with no further hospital readmissions.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Although there are only a few cases described in the literature,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1–4</span></a> this report shows that implantation of a CRT system through a femoral approach is feasible and sometimes relatively easy, with good stability of the leads at nine-month follow-up. In patients with comorbidities and high surgical risk it can be a good alternative to the epicardial approach.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protection of human and animal subjects</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Confidentiality of data</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres831944" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec827779" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres831943" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec827778" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Right to privacy and informed consent" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-03-04" "fechaAceptado" => "2016-07-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec827779" "palabras" => array:3 [ 0 => "Cardiac resynchronization system" 1 => "Femoral approach" 2 => "Heart failure" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec827778" "palabras" => array:3 [ 0 => "Sistema de ressincronização ventricular" 1 => "Via femoral" 2 => "Insuficiência cardíaca" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe the case of a 62-year-old female patient with bilateral subclavian vein occlusion, in whom a cardiac resynchronization system was implanted via a femoral vein.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os autores descrevem a implantação de sistema de ressincronização ventricular por via femoral, em doente do sexo feminino, 62 anos, com oclusão bilateral da veia subclávia.</p></span>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1203 "Ancho" => 1469 "Tamanyo" => 136134 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Coronary sinus venography, left anterior oblique view, demonstrating the target posterolateral branch of the coronary sinus.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1208 "Ancho" => 1485 "Tamanyo" => 166178 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Left anterior oblique view of final lead positions in the right atrium, right ventricle, and the posterolateral branch of the coronary sinus.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1220 "Ancho" => 1497 "Tamanyo" => 106105 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Right anterior oblique view of final lead positions in the right atrium, right ventricle, and the posterolateral branch of the coronary sinus.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1503 "Ancho" => 1531 "Tamanyo" => 122244 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Chest radiograph, lateral view, one day after the procedure.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac resynchronization via the femoral vein: a novel method in cases with contraindications to the pectoral approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Z. 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Williams" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/europace/euu340" "Revista" => array:5 [ "tituloSerie" => "Europace" "fecha" => "2015" "volumen" => "17" "paginaInicial" => "173" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25488956" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003600000004/v1_201704230025/S2174204917300934/v1_201704230025/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003600000004/v1_201704230025/S2174204917300934/v1_201704230025/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917300934?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 6 | 14 |
| 2024 October | 36 | 21 | 57 |
| 2024 September | 44 | 22 | 66 |
| 2024 August | 41 | 32 | 73 |
| 2024 July | 33 | 21 | 54 |
| 2024 June | 33 | 20 | 53 |
| 2024 May | 51 | 18 | 69 |
| 2024 April | 51 | 25 | 76 |
| 2024 March | 32 | 22 | 54 |
| 2024 February | 37 | 30 | 67 |
| 2024 January | 33 | 29 | 62 |
| 2023 December | 23 | 31 | 54 |
| 2023 November | 39 | 32 | 71 |
| 2023 October | 27 | 13 | 40 |
| 2023 September | 26 | 18 | 44 |
| 2023 August | 17 | 14 | 31 |
| 2023 July | 28 | 14 | 42 |
| 2023 June | 32 | 13 | 45 |
| 2023 May | 34 | 20 | 54 |
| 2023 April | 44 | 3 | 47 |
| 2023 March | 37 | 27 | 64 |
| 2023 February | 36 | 22 | 58 |
| 2023 January | 36 | 11 | 47 |
| 2022 December | 30 | 18 | 48 |
| 2022 November | 50 | 25 | 75 |
| 2022 October | 38 | 19 | 57 |
| 2022 September | 34 | 34 | 68 |
| 2022 August | 30 | 29 | 59 |
| 2022 July | 37 | 34 | 71 |
| 2022 June | 28 | 17 | 45 |
| 2022 May | 33 | 31 | 64 |
| 2022 April | 37 | 26 | 63 |
| 2022 March | 36 | 40 | 76 |
| 2022 February | 45 | 29 | 74 |
| 2022 January | 51 | 21 | 72 |
| 2021 December | 24 | 28 | 52 |
| 2021 November | 31 | 37 | 68 |
| 2021 October | 64 | 45 | 109 |
| 2021 September | 64 | 25 | 89 |
| 2021 August | 40 | 35 | 75 |
| 2021 July | 11 | 24 | 35 |
| 2021 June | 33 | 20 | 53 |
| 2021 May | 35 | 43 | 78 |
| 2021 April | 26 | 39 | 65 |
| 2021 March | 47 | 15 | 62 |
| 2021 February | 50 | 23 | 73 |
| 2021 January | 28 | 13 | 41 |
| 2020 December | 37 | 7 | 44 |
| 2020 November | 40 | 16 | 56 |
| 2020 October | 28 | 11 | 39 |
| 2020 September | 59 | 10 | 69 |
| 2020 August | 35 | 12 | 47 |
| 2020 July | 56 | 13 | 69 |
| 2020 June | 39 | 16 | 55 |
| 2020 May | 34 | 3 | 37 |
| 2020 April | 39 | 30 | 69 |
| 2020 March | 48 | 12 | 60 |
| 2020 February | 65 | 17 | 82 |
| 2020 January | 45 | 6 | 51 |
| 2019 December | 34 | 12 | 46 |
| 2019 November | 27 | 6 | 33 |
| 2019 October | 49 | 9 | 58 |
| 2019 September | 23 | 8 | 31 |
| 2019 August | 23 | 9 | 32 |
| 2019 July | 37 | 11 | 48 |
| 2019 June | 23 | 23 | 46 |
| 2019 May | 45 | 4 | 49 |
| 2019 April | 24 | 22 | 46 |
| 2019 March | 86 | 10 | 96 |
| 2019 February | 94 | 8 | 102 |
| 2019 January | 76 | 6 | 82 |
| 2018 December | 111 | 11 | 122 |
| 2018 November | 96 | 14 | 110 |
| 2018 October | 101 | 17 | 118 |
| 2018 September | 33 | 14 | 47 |
| 2018 August | 24 | 4 | 28 |
| 2018 July | 18 | 5 | 23 |
| 2018 June | 33 | 5 | 38 |
| 2018 May | 29 | 10 | 39 |
| 2018 April | 40 | 7 | 47 |
| 2018 March | 31 | 6 | 37 |
| 2018 February | 14 | 3 | 17 |
| 2018 January | 28 | 8 | 36 |
| 2017 December | 31 | 5 | 36 |
| 2017 November | 32 | 10 | 42 |
| 2017 October | 26 | 6 | 32 |
| 2017 September | 17 | 9 | 26 |
| 2017 August | 34 | 13 | 47 |
| 2017 July | 18 | 8 | 26 |
| 2017 June | 42 | 12 | 54 |
| 2017 May | 63 | 22 | 85 |
| 2017 April | 10 | 6 | 16 |
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