AJR 2001; 177:1447-1450
© American Roentgen Ray Society
Radiographic Appearance of Biventricular Pacing for the Treatment of Heart Failure
Philip N. Cascade1,
Michael B. Sneider1,
Todd M. Koelling2 and
Bradley P. Knight2
1
Department of Radiology, University of Michigan Health System, 1500 E. Medical
Center Dr., TC 2910L, Ann Arbor, MI 48109-0326
2
Department of Internal Medicine, University of Michigan Health System, Ann
Arbor, MI 48109-0326.
Received March 22, 2001;
accepted after revision May 18, 2001.
Address correspondence to P. N. Cascade.
Introduction
Patients with severe chronic heart failure receive pharmacologic treatment
as the primary intervention. Failure of medical therapy can lead to more
aggressive treatment such as long-term support with artificial assist devices
and heart transplantation. Progress has been made toward development of a
promising treatment for a subset of patients with dilated cardiomyopathy and
intraventricular conduction delay
[1,2,3].
Prolonged conduction results in asynchronous contraction and reduced cardiac
output. Treatment with pacing can increase cardiac output and can increase
exercise tolerance by synchronizing contraction of the cardiac chambers with
biventricular or left ventricular pacing alone as the most effective strategy.
As this treatment gains acceptance, radiologists should be familiar with the
radiographic appearance of left ventricular pacing. We describe the
radiographic appearance of biventricular pacing, including coronary venous
lead placement to stimulate the left ventricle.
Physiologic Basis for Biventricular Pacing
Patients with severe heart failure and intraventricular conduction delay
have uncoordinated cardiac contractions
[1]. Resynchronization with
combined left and right ventricular chamber pacing (biventricular), or
stimulating the left ventricle alone, yields considerable systolic benefits
compared with right-sided stimulation alone. Improved sequencing of muscular
contractions through the left ventricle is the probable explanation for
improvement in systolic function. The site of stimulation of the left
ventricle impacts the degree of functional improvement
[2,
3]. Therefore,
electrophysiologic mapping of the optimum stimulation point is important, and
methods of placing the pacing electrodes must be flexible. An additional
benefit of resynchronization occurs in patients with prolonged
atrioventricular conduction and mitral or tricuspid valve regurgitation.
Atrioventricular valve regurgitation caused by early and incomplete closure of
the valve interferes with diastolic filling. Biventricular pacing optimizes
mechanics of the atrioventricular valves, thus reducing regurgitation and
improving stroke volume, cardiac output, and exercise tolerance. Arrhythmia is
a common cause of death in this group of patients. Therefore, intravascular
defibrillators are often placed in addition to pacing electrodes.
Coronary Venous Anatomy
The myocardium drains by three communicating venous systems. The major
system drains most of the left ventricular myocardium and terminates by
emptying into the right atrium via the coronary sinus. The veins of the right
ventricle, the second venous system, empty separately into the right atrium.
The thebesian veins, the third system of tiny veins, drain directly into the
cardiac chambers. There is considerable variation in the smaller coronary
veins; however, the major veins are relatively constant
[4,
5].
Figure
1A,1B
is a diagram of the major coronary veins in the frontal and lateral
projections. Most of the venous drainage of the left ventricle is through the
anterior interventricular, posterior interventricular, and obtuse marginal
veins. The anterior interventricular vein becomes known as the great cardiac
vein when it enters the atrioventricular groove. The great cardiac vein
transitions to the coronary sinus in the mid atrioventricular groove at the
venous valve of Vieussens and at the point of entry of a small left atrial
vein called the oblique vein of Marshall. The coronary sinus drains into the
inferoposterior aspect of the right atrium. The obtuse marginal vein, also
referred to as the "middle cardiac vein," drains the
posterolateral aspect of the left ventricle, joining the great cardiac vein in
the posterior atrioventricular groove. The posterior interventricular vein
drains the inferior aspect of the left ventricle, emptying into the coronary
sinus adjacent to the right atrium.
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Fig. 1A. —Major epicardial coronary veins. Drawing in frontal
projection shows that anterior interventricular (AIV) and obtuse marginal
(OMV) veins drain into great cardiac vein (GCV). Oblique vein of Marshall (VM)
drains into coronary sinus (CS) at level of venous valve of Vieussens, marking
point of transition of coronary sinus and great cardiac vein in mid
atrioventricular groove. Posterior interventricular vein (PIV) joins coronary
sinus near ostium to right atrium.
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Fig. 1B. —Major epicardial coronary veins. Drawing in lateral
projection shows that anterior interventricular vein (AIV) and obtuse marginal
vein (OMV) drain into great cardiac vein (GCV). Posterior interventricular
vein (PIV) joins coronary sinus (CS) near ostium to right atrium.
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Technique of Placing Coronary Venous Pacers
The customary approach for left ventricle pacer placement has been by
thoracotomy or thoracoscopy. However, advances in technology now allow
percutaneous lead placement in epicardial veins for chronic pacing of the left
ventricle, a less invasive procedure compared with thoracotomy or
thoracoscopy. In the initial experience of percutaneous lead placement,
problems of maneuverability and dislodgment were frequent. However, placement
and fixation of electrodes have improved with advances in technology.
Auricchio et al. [3] have
described the procedure and equipment in detail. A special catheter guide,
designed for use in enlarged hearts, is passed into the coronary sinus. An
occluding balloon at the catheter tip aids contrast filling of the coronary
veins, used as a "road map" for electrode placement
(Fig. 2). The pacing lead is
then advanced into a coronary vein through the coronary sinus catheter. In
some patients, proper pacer placement is technically difficult. Therefore,
some leads are designed with an open lumen, allowing passage over a guidewire
to facilitate positioning. With this coaxial technique, a flexible guidewire
is first passed through the coronary sinus catheter into the desired position.
The open lumen lead is then passed over the guidewire to the desired location
and fixed in position by a tinelike configuration at the tip.
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Fig. 2. —71-year-old man with ischemic dilated cardiomyopathy,
undergoing placement of pacing electrode in coronary vein. Left anterior
oblique coronary venous cineangiogram serves as "road map" to
facilitate placement of pacing electrodes in epicardial veins on left
ventricular surface. Cineangiogram was obtained by retrograde injection of
contrast material through coronary sinus. Occluding balloon at ostium of
coronary sinus (asterisk) prevents drainage of contrast material into
right atrium. Great cardiac (solid arrow) and posterior
interventricular (open arrow) veins are opacified with contrast
material.
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Radiographic Appearance
Some patients will have had placement of left ventricular epicardial leads
through a minithoracotomy or by thoracoscopy
(Fig. 3). Radiographs in these
patients show the surgically implanted transthoracic leads extending to the
surface of the left ventricle, in addition to typical pacing electrodes in the
right atrial appendage and right ventricular apex. However, most patients have
the left ventricular electrodes within the coronary veins. The most common
site for lead placement is the anterior interventricular vein, located in the
anterior interventricular groove (Fig.
4A,4B).
In some patients, left ventricular pacing occurs at other sites such as the
obtuse marginal (middle) cardiac vein (Fig.
5), located on the mid posterior surface of the left ventricle. On
occasion, the left ventricular pacing electrode can extend into a side branch
of a vein (Fig. 6). Many
patients with biventricular-pacing electrodes will also have intravascular
defibrillating electrodes.
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Fig. 3. —Left ventricular epicardial leads placed by minithoracotomy
in 42-year-old man undergoing biventricular pacing for nonischemic dilated
cardiomyopathy. Radiograph shows typical positioning of defibrillating
electrodes at superior vena cava—right atrial junction (open
arrow) and right ventricular apex (asterisk). Pacing electrode
resides in right atrial appendage (solid arrow). Left ventricular
epicardial electrodes were attached through minithoracotomy
(arrowheads).
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Fig. 4A. —Biventricular pacing using anterior interventricular vein in
57-year-old man with idiopathic dilated cardiomyopathy. Frontal chest
radiograph shows left ventricular pacing lead extending from right atrium
retrograde into coronary sinus, through greater cardiac vein
(arrowheads), and into anterior interventricular vein
(asterisk) located on surface of left ventricle.
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Fig. 4B. —Biventricular pacing using anterior interventricular vein in
57-year-old man with idiopathic dilated cardiomyopathy. Lateral chest
radiograph shows left ventricular pacing lead extending from right atrium into
coronary sinus and through greater cardiac vein (arrowheads) into
anterior interventricular vein (asterisk) located on surface of left
ventricle.
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Fig. 5. —Biventricular pacing using obtuse marginal (middle) cardiac
vein in 29-year-old man with cardiomyopathy related to congenital heart
disease. Anteroposterior chest radiograph obtained bedside shows pacing lead
(asterisk) in obtuse marginal vein draining posterolateral aspect of
left ventricle.
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Fig. 6. —46-year-old man with idiopathic dilated cardiomyopathy
undergoing biventricular pacing. Posteroanterior chest radiograph shows
extension of left ventricular lead (asterisk) from anterior
interventricular vein into side branch.
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In conclusion, an innovative technique using pacing to treat patients with
heart failure has been developed. Several international trials are currently
investigating the safety and outcome of biventricular pacing as a treatment
for severe chronic heart failure associated with intraventricular conduction
delay. In addition, a recent report
[6] hints that temporary
biventricular pacing may be helpful for patients in acute heart failure.
Therefore, radiologists should be familiar with the technology of
biventricular pacing, should understand the physiologic basis for treatment,
and should know coronary venous anatomy to provide informative interpretations
of chest radiographs.
References
-
Auricchio A, Stellbrink C, Block M, et al. Effect of pacing chamber
and atrioventricular delay on acute systolic function of paced patients with
congestive heart failure. Circulation
1999;99:2993
-3001[Abstract/Free Full Text]
-
Auricchio A, Stellbrink C, Sack S, et al. The Pacing Therapies for
Congestive Heart Failure (PATH-CHF) study: rationale, design, and end-points
of a prospective randomized multicenter study. Am J
Cardiol 1999;83:130D
-135D[Medline]
-
Auricchio A, Klein H, Tockman B, et al. Transvenous biventricular
pacing for heart failure: can the obstacles be overcome? Am J
Cardiol 1999; 83:136D
-142D[Medline]
-
James TN. Anatomy of the coronary arteries,
1st ed. Hagerstown, MD: Harper & Row, 1961:173
-207
-
Gensini GG, Di Giorgi S, Coskun O, Palacio A, Kelly AE. Anatomy of
the coronary circulation in living man: coronary venography.
Circulation
1965;31:778
-784[Free Full Text]
-
Debrunner M, Naegeli B, Bertel O. The acute effects of transvenous
biventricular pacing in a patient with congestive heart failure.
Chest
2000;117:1798
-1800[Abstract/Free Full Text]
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Introduction
Physiologic Basis for...
