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
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Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
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White arrows indicate the intimal flap; (F and G) IVUS and OCT, respectively, after stent implantation, showing correct expansion and apposition; (H and I) IVUS and OCT, respectively, displaying the hematoma at the origin of a patent septal branch (star); (J) three-dimensional (3-D) OCT reconstruction at the same level as (I); (K) 3-D reconstruction after implantation of the first stent. The cross shows the hematoma and the luminal compromise; (L and M) final 3-D result. IVUS: intravascular ultrasound; OCT: optical coherence tomography.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Iván J. Núñez-Gil, Mauro Echavarría-Pinto, Gisela Feltes, Antonio Fernández-Ortiz" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Iván J." 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array:3 [ "EPUB" => 201 "HTML" => 2428 "PDF" => 538 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Pericardial mesothelioma presenting as a suspected ST-elevation myocardial infarction" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "307.e1" "paginaFinal" => "307.e5" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Apresentação de mesotelioma do pericárdio como suspeita de enfarte agudo do miocárdio com elevação de ST" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 936 "Ancho" => 932 "Tamanyo" => 107116 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography revealing a long 50% stenosis in the mid-distal portion of the left anterior descending artery and a 30% focal stenosis in the mid segment of the right coronary artery.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Sofia Barroso, Sérgio Leite, Fernando Friões, Mariana Vasconcelos, Daniela Azevedo, Helena Baldaia, Mário Jorge Amorim, Paula Dias" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Ana Sofia" "apellidos" => "Barroso" ] 1 => array:2 [ "nombre" => "Sérgio" "apellidos" => "Leite" ] 2 => array:2 [ "nombre" => "Fernando" "apellidos" => "Friões" ] 3 => array:2 [ "nombre" => "Mariana" "apellidos" => "Vasconcelos" ] 4 => array:2 [ "nombre" => "Daniela" "apellidos" => "Azevedo" ] 5 => array:2 [ "nombre" => "Helena" "apellidos" => "Baldaia" ] 6 => array:2 [ "nombre" => "Mário Jorge" "apellidos" => "Amorim" ] 7 => array:2 [ "nombre" => "Paula" "apellidos" => "Dias" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117301543?idApp=UINPBA00004E" "url" => "/08702551/0000003600000004/v1_201704060057/S0870255117301543/v1_201704060057/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" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 722 "Ancho" => 881 "Tamanyo" => 70443 ] ] "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>" ] ] ] "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" => "xres825041" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec821511" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres825040" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec821512" "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" => "xpalclavsec821511" "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" => "xpalclavsec821512" "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" => 722 "Ancho" => 881 "Tamanyo" => 70443 ] ] "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" => 725 "Ancho" => 891 "Tamanyo" => 87679 ] ] "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" => 732 "Ancho" => 898 "Tamanyo" => 57645 ] ] "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" => 901 "Ancho" => 918 "Tamanyo" => 61138 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Chest radiograph, lateral view, one day after the 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 6 | 4 | 10 |
| 2024 Outubro | 34 | 34 | 68 |
| 2024 Setembro | 38 | 26 | 64 |
| 2024 Agosto | 42 | 34 | 76 |
| 2024 Julho | 33 | 29 | 62 |
| 2024 Junho | 31 | 22 | 53 |
| 2024 Maio | 42 | 16 | 58 |
| 2024 Abril | 46 | 28 | 74 |
| 2024 Maro | 48 | 22 | 70 |
| 2024 Fevereiro | 37 | 22 | 59 |
| 2024 Janeiro | 35 | 21 | 56 |
| 2023 Dezembro | 37 | 28 | 65 |
| 2023 Novembro | 43 | 21 | 64 |
| 2023 Outubro | 29 | 13 | 42 |
| 2023 Setembro | 21 | 19 | 40 |
| 2023 Agosto | 30 | 21 | 51 |
| 2023 Julho | 26 | 9 | 35 |
| 2023 Junho | 26 | 13 | 39 |
| 2023 Maio | 41 | 18 | 59 |
| 2023 Abril | 23 | 6 | 29 |
| 2023 Maro | 31 | 19 | 50 |
| 2023 Fevereiro | 23 | 16 | 39 |
| 2023 Janeiro | 27 | 10 | 37 |
| 2022 Dezembro | 32 | 15 | 47 |
| 2022 Novembro | 31 | 21 | 52 |
| 2022 Outubro | 36 | 23 | 59 |
| 2022 Setembro | 31 | 41 | 72 |
| 2022 Agosto | 28 | 34 | 62 |
| 2022 Julho | 35 | 32 | 67 |
| 2022 Junho | 21 | 28 | 49 |
| 2022 Maio | 29 | 27 | 56 |
| 2022 Abril | 38 | 31 | 69 |
| 2022 Maro | 29 | 39 | 68 |
| 2022 Fevereiro | 25 | 26 | 51 |
| 2022 Janeiro | 30 | 23 | 53 |
| 2021 Dezembro | 25 | 33 | 58 |
| 2021 Novembro | 34 | 40 | 74 |
| 2021 Outubro | 35 | 42 | 77 |
| 2021 Setembro | 34 | 32 | 66 |
| 2021 Agosto | 41 | 44 | 85 |
| 2021 Julho | 29 | 33 | 62 |
| 2021 Junho | 32 | 17 | 49 |
| 2021 Maio | 35 | 35 | 70 |
| 2021 Abril | 60 | 27 | 87 |
| 2021 Maro | 63 | 25 | 88 |
| 2021 Fevereiro | 72 | 16 | 88 |
| 2021 Janeiro | 40 | 10 | 50 |
| 2020 Dezembro | 31 | 12 | 43 |
| 2020 Novembro | 55 | 16 | 71 |
| 2020 Outubro | 36 | 13 | 49 |
| 2020 Setembro | 51 | 9 | 60 |
| 2020 Agosto | 23 | 11 | 34 |
| 2020 Julho | 49 | 12 | 61 |
| 2020 Junho | 46 | 14 | 60 |
| 2020 Maio | 42 | 4 | 46 |
| 2020 Abril | 45 | 14 | 59 |
| 2020 Maro | 41 | 10 | 51 |
| 2020 Fevereiro | 84 | 33 | 117 |
| 2020 Janeiro | 36 | 7 | 43 |
| 2019 Dezembro | 22 | 9 | 31 |
| 2019 Novembro | 38 | 8 | 46 |
| 2019 Outubro | 48 | 7 | 55 |
| 2019 Setembro | 14 | 7 | 21 |
| 2019 Agosto | 37 | 12 | 49 |
| 2019 Julho | 40 | 12 | 52 |
| 2019 Junho | 36 | 20 | 56 |
| 2019 Maio | 64 | 19 | 83 |
| 2019 Abril | 25 | 17 | 42 |
| 2019 Maro | 84 | 8 | 92 |
| 2019 Fevereiro | 53 | 12 | 65 |
| 2019 Janeiro | 35 | 11 | 46 |
| 2018 Dezembro | 50 | 13 | 63 |
| 2018 Novembro | 87 | 13 | 100 |
| 2018 Outubro | 105 | 18 | 123 |
| 2018 Setembro | 46 | 14 | 60 |
| 2018 Agosto | 23 | 9 | 32 |
| 2018 Julho | 18 | 7 | 25 |
| 2018 Junho | 29 | 5 | 34 |
| 2018 Maio | 41 | 8 | 49 |
| 2018 Abril | 51 | 7 | 58 |
| 2018 Maro | 86 | 12 | 98 |
| 2018 Fevereiro | 37 | 8 | 45 |
| 2018 Janeiro | 60 | 8 | 68 |
| 2017 Dezembro | 84 | 12 | 96 |
| 2017 Novembro | 62 | 13 | 75 |
| 2017 Outubro | 25 | 10 | 35 |
| 2017 Setembro | 22 | 16 | 38 |
| 2017 Agosto | 31 | 11 | 42 |
| 2017 Julho | 31 | 17 | 48 |
| 2017 Junho | 48 | 19 | 67 |
| 2017 Maio | 76 | 33 | 109 |
| 2017 Abril | 56 | 57 | 113 |
| 2017 Maro | 5 | 6 | 11 |
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