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The introduction of dedicated tools for pacing and defibrillator lead extraction has resulted in relatively high success and low complication rates. The confidence this elicits has broadened the indications from device infections to non-functional or redundant leads and the latter make up an increasing share of extraction procedures. Proponents of extracting these leads point to the higher complication burden of lead extraction in patients with longstanding abandoned leads when compared one-to-one with extraction when these leads become redundant. However, this does not translate into better patient outcomes on a population level: complications are rare with properly abandoned leads and thus most patients will never be subjected to an extraction procedure and the ensuing complications. Therefore, not extracting redundant leads minimises the risk for the patients and avoids many expensive procedures.

Background Venous access for cardiac implantable electronic devices (CIED) is commonly performed by cephalic venous cut down, or axillary or subclavian vein puncture. The latter technique carries a risk of complications such as pneumothorax or lead crush. Cephalic venous cut down is free of these complications but often less successful due to technical difficulties. We report a highly successful, simplified cephalic venous access with a modified Seldinger technique. Methods We prospectively studied 221 patients undergoing de novo implantation of a one, two, or three lead device system performed over a 1-year period at our center, and assessed the efficacy of the cephalic vein access including the number of leads successfully placed for each procedure. Results In 83% of patients undergoing CIED implantation, a suitable cephalic vein was present. In respectively 98% and 99% of patients undergoing single- or dual-chamber CIED implantation, lead placement could be performed exclusively via the cephalic vein and in 72% of cardiac resynchronization therapy implants, all three leads were placed via cephalic access. Conclusion A novel, technically simple cephalic venous catheterization technique provides high success rates for any CIED lead implantation.

Right ventricular pacing (RVP) induces abnormal electrical activation and asynchronous ventricular contraction and leads to pacing induced cardiomyopathy (PICM) in 10%-20% of patients. Cardiac resynchronization therapy (CRT) utilizing biventricular pacing (BVP) is the recommended treatment. Left bundle branch pacing (LBBP) is a novel physiological pacing technique which may serve as an alternative to CRT. This study assessed feasibility and outcomes of LBBP delivered CRT in patients with PICM.Total 20 consecutive patients with PICM who received an upgrade of their pacemaker to LBBP were prospectively studied. Acute success rate, complications, functional and echocardiographic response, and hospitalization for heart failure within 6 months from implantation were evaluated.LBBP was successfully delivered in all patients. Median duration of RVP before upgrade to LBBP was 3.8 years and the RVP was 99%. LBBP resulted in significant QRS narrowing (from 193 ± 18 ms to 130 ± 17 ms [p .001]), improvement in LVEF (from 32% ± 6 % to 47% ± 8% [p .001]) and NYHA class (from 2.8 ± 0.4 to 1.4 ± 0.5 [p .001]) at 6 months. No LBBP-related complications occurred. No patients were hospitalized for heart failure or died.LBBP is feasible and safe in delivering CRT in PICM. Preliminary analyses demonstrated significant electrical resynchronization and favorable improvement in LV function and NYHA functional class at short term follow-up. Data needs to be validated in large randomized controlled trials.

Aims This study was performed to develop and externally validate prediction models for appropriate implantable cardioverter-defibrillator (ICD) shock and mortality to identify subgroups with insufficient benefit from ICD implantation. Methods and results We recruited patients scheduled for primary prevention ICD implantation and reduced left ventricular function. Bootstrapping-based Cox proportional hazards and Fine and Gray competing risk models with likely candidate predictors were developed for all-cause mortality and appropriate ICD shock, respectively. Between 2014 and 2018, we included 1441 consecutive patients in the development and 1450 patients in the validation cohort. During a median follow-up of 2.4 (IQR 2.1–2.8) years, 109 (7.6%) patients received appropriate ICD shock and 193 (13.4%) died in the development cohort. During a median follow-up of 2.7 (IQR 2.0–3.4) years, 105 (7.2%) received appropriate ICD shock and 223 (15.4%) died in the validation cohort. Selected predictors of appropriate ICD shock were gender, NSVT, ACE/ARB use, atrial fibrillation history, Aldosterone-antagonist use, Digoxin use, eGFR, (N)OAC use, and peripheral vascular disease. Selected predictors of all-cause mortality were age, diuretic use, sodium, NT-pro-BNP, and ACE/ARB use. C-statistic was 0.61 and 0.60 at respectively internal and external validation for appropriate ICD shock and 0.74 at both internal and external validation for mortality. Conclusion Although this cohort study was specifically designed to develop prediction models, risk stratification still remains challenging and no large group with insufficient benefit of ICD implantation was found. However, the prediction models have some clinical utility as we present several scenarios where ICD implantation might be postponed.

Background: The World-wide Randomized Antibiotic Envelope Infection Prevention trial reported a 40% reduction in major cardiac implantable electronic device (CIED) infections within 12 months of the procedure with the use of an antibacterial-eluting envelope (TYRX Absorbable Antibacterial Envelope, Medtronic, Mounds View, MN). Objective: The purpose of this report was to describe the longer-term (>12 months) envelope effects on infection reduction and complications. Methods: All trial patients who underwent CIED replacement, upgrade, revision, or initial cardiac resynchronization therapy – defibrillator implantation received standard-of-care infection prophylaxis and were randomized in a 1:1 ratio to receive the envelope or not. CIED infection incidence and procedure and system-related complications were characterized through all follow-up (36 months) by using Cox proportional hazards regression modeling. Results: In total, 6800 patients received their intended randomized treatment (3371 envelope; 3429 control; mean follow-up period 21.0 ± 8.3 months). Major CIED-related infections occurred in 32 envelope patients and 51 control patients (Kaplan-Meier [KM] estimate 1.3% vs 1.9%; hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.41–0.99; P = .046). Any CIED-related infection occurred in 57 envelope patients and 84 control patients (KM estimate 2.1% vs 2.8%; HR 0.69; 95% CI 0.49–0.97; P = .030). System- or procedure-related complications occurred in 235 envelope patients and 252 control patients (KM estimate 8.0% vs 8.2%; HR 0.95; 95% CI 0.79–1.13; P < .001 for noninferiority); the most common were lead dislodgment (1.1%), device lead damage (0.5%), and implant site hematoma (0.4%). Implant site pain occurred less frequently in the envelope group (0.1% vs 0.4%; P = .067). There were no (0.0%) reports of allergic reactions to the components of the envelope (mesh, polymer, or antibiotics). Conclusion: The effects of the TYRX envelope on the reduction of the risk of CIED infection are sustained beyond the first year postprocedure, without an increased risk of complications.

The interaction of influenza infection with the pathogenesis of acute heart failure (AHF) and the worsening of chronic heart failure (CHF) is rather complex. The deleterious effects of influenza infection on AHF/CHF can be attenuated by specific immunization. Our review aimed to summarize the efficacy, effectiveness, safety, and dosage of anti-influenza vaccination in HF. In this literature review, we searched MEDLINE and EMBASE from January 1st 1966 to December 31st, 2016, for studies examining the association between AHF/CHF, influenza infections, and anti-influenza immunizations. We used broad criteria to increase the sensitivity of the search. HF was a prerequisite for our search. The search fields used included "heart failure," "vaccination," "influenza," "immunization" along with variants of these terms. No restrictions on the type of study design were applied. The most common clinical scenario is exacerbation of pre-existing CHF by influenza infection. Scarce evidence supports a potential positive association of influenza infection with AHF. Vaccinated patients with pre-existing CHF have reduced all-cause morbidity and mortality, but effects are not consistently documented. Immunization with higher antigen quantity may confer additional protection, but such aggressive approach has not been generally advocated. Further studies are needed to delineate the role of influenza infection on AHF/CHF pathogenesis and maintenance. Annual anti-influenza vaccination appears to be an effective measure for secondary prevention in HF. Better immunization strategies and more efficacious vaccines are urgently necessary.

Background: The Heart Team approach has become an integral part of modern cardiovascular medicine. To evaluate current opinions and real-world practice among lead extraction practitioners, an online survey was created and distributed among a pool of lead extraction specialists participating in the International Lead Extraction Expert Meeting (ILEEM) 2018. Methods: The online survey consisted of 10 questions and was performed using an online survey tool (www.surveymonkey.com). The collector link was sent to 48 lead extraction experts via email. Results: A total of 43 answers were collected (89% return rate) from lead extraction experts in 16 different countries. A great majority (83.7%) of the respondents performed more than 30 lead extraction procedures per year. The most common procedural environment in this survey was the hybrid operating room (67.4%). Most procedures were performed by electrophysiologists and cardiologists (80.9%). Important additional members of the current lead extraction teams were cardiac surgeons (79.1%), anesthesiologists (95.3%) and operating room scrub nurses (76.7%). An extended Heart Team is regarded beneficial for patient care by 86.0%, with potential further members being infectious diseases specialists, intensivists and radiologists. Team training activities are performed in 48.8% of participating centers. Conclusions: This survey supports the importance of establishing lead extraction Heart Teams in specialized lead extraction centers to potentially improve patient outcomes. The concept of a core and an extended heart team approach in lead extraction procedures is introduced.

Aims Abandoned leads are often linked to complications during lead extraction, prompting pre-emptive extraction if leads become non-functional. We examined their influence on complications when extracted for device-related infection. Methods and results All patients undergoing lead extraction for device-related infection from 2006 to 2017 in our hospital were included. The primary endpoint was major complications. Out of 500 patients, 141 had abandoned leads, of whom 75% had only one abandoned lead. Median cumulative implant times were 24.2 (interquartile range 15.6–38.2) and 11.6 (5.6–17.4), respectively years with or without abandoned leads. All leads were extracted only with a femoral approach in 50.4% of patients. Mechanical rotational tools were introduced in 2014 and used in 22.2% of cases and replacing laser sheaths that were used in 5% of patients. Major complications occurred in 0.7% of patients with abandoned leads compared with 1.7% of patients with only active leads (P = 0.679). Failure to completely remove all leads was 14.9% and 6.4%, respectively with or without abandoned leads (P = 0.003), and clinical failure was 6.4% and 2.2% (P = 0.028), respectively. Procedural failure dropped to 9.2% and 5.7% (P = 0.37), respectively after the introduction of mechanical rotational tools. The only independent predictor of procedural and clinical failure in multivariate analysis was the cumulative implant duration. Conclusion Despite longer implant times, patients with abandoned leads did not have more major complications during lead extraction. Therefore, preventive extraction of non-functional leads to avoid complications at a later stage is not warranted.

Objectives The purpose of this study was to investigate whether stimulation at the left ventricular (LV) septum (LVs), alone or in combination with another site, could be an alternative way to apply cardiac resynchronization therapy (CRT) that avoids the coronary sinus and phrenic nerve stimulation and may create more physiological sequence of activation. Background In CRT, biventricular pacing is commonly performed from the right ventricle (RV) and the epicardium of the LV lateral wall (LVlat). In the left bundle branch block (LBBB), half of the electrical delay occurs due to impulse conduction across the septum. Methods Experiments were performed in 13 dogs with LBBB, 7 of them with chronic myocardial infarction (LBBB + MI). Pacing leads were positioned in the right atrium, RV, LVs, and at the LVlat epicardium. LV pump function was measured using conductance catheter and synchrony of electrical activation of the ventricles using epicardial mapping and from surface electrocardiogram. In 12 CRT patients, LV pump function was measured during temporary RV + LVs pacing and compared to RV + LVlat and RV + LVlat endo pacing. Results In the animals, electrical and hemodynamic benefits of LVs and RV + LVs pacing were comparable to those during conventional biventricular pacing and were comparable in LBBB and LBBB + MI hearts. Dispersion of repolarization was reduced by LVs stimulation, but not by LVlat pacing. In patients, hemodynamic benefits of RV + LVs, RV + LVlat and RV + LVlat endo pacing were similar. Conclusions The use of the LVs as LV pacing site in CRT improves synchronization and acute hemodynamics comparably to conventional biventricular pacing in dyssynchronous canines and in patients. In addition, LVs stimulation may reduce dispersion of repolarization compared to epicardial pacing.

AIMS: The optimal site for biventricular endocardial (BIV(ENDO)) pacing remains undefined. Acute haemodynamic response (AHR) is reproducible marker of left ventricular (LV) contractility, best expressed as the change in the maximum rate of LV pressure (LV-dp/dt(max)), from a baseline state. We examined the relationship between factors known to impact LV contractility, whilst delivering BIV(ENDO) pacing at a variety of LV endocardial (LV(ENDO)) locations. METHODS AND RESULTS: We compiled a registry of acute LV(ENDO) pacing studies from five international centres: Johns Hopkins-USA, Bordeaux-France, Eindhoven-The Netherlands, Oxford-United Kingdom, and Guys and St Thomas’ NHS Foundation Trust, London-UK. In all, 104 patients incorporating 687 endocardial and 93 epicardial pacing locations were studied. Mean age was 66 ± 11 years, mean left ventricular ejection fraction 24.6 ± 7.7% and mean QRS duration of 163 ± 30 ms. In all, 50% were ischaemic [ischaemic cardiomyopathy (ICM)]. Scarred segments were associated with worse haemodynamics (dp/dt(max); 890 mmHg/s vs. 982 mmHg/s, P 50%) achieved greater increases in AHR than non-late activating tissue (LVLED 50%) yields greater improvements in AHR however, the optimal location is frequently not the site of latest activation.

Background We studied the acute hemodynamic effect of left ventricular (LV) pacing from a dual cathodal coronary sinus (CS) lead in a both single- and dual-site electrode configuration. Methods In 17 patients who underwent implantation of a cardiac resynchronization therapy-defibrillator system with dual cathodal CS leads, LV stimulation was performed from the distal and proximal electrode separately and from both electrodes simultaneously. The acute hemodynamic response was evaluated by invasive measurement of LVdP/dtmax. Timing of LV electrical activation time measured from onset QRS to LV sense during intrinsic rhythm at both electrodes were determined from simultaneous intracardiac recordings. The latter results were compared to those of an additional group of 26 patients in whom no hemodynamic effects were evaluated. Results Baseline LVdP/dtmax was 897 ± 222 mm Hg/s. Single-site LV pacing resulted in a rise of LVdP/dtmax to 1,053 ± 266 mm Hg/s (+17.4%) taking the best of the two sites and 1,020 ± 254 mm Hg (+13.7%) at the worst site (P = 0.0001). In the dual-site pacing configuration LVdP/dtmax was 1,026 ± 243 mm Hg/s (+14.1%). P value for single best versus dual site was 0.005, and for dual site versus worst single site was 0.18 (n.s.). Conclusion Even with a relatively small distance of 20–21 mm between stimulation electrodes, there is a significant difference in acute hemodynamic effect from the single best and worst site. Dual-site LV pacing offers no hemodynamic benefit over the best single pacing site. The short electrode distance may have been a limitation and results may not be applicable to other forms of multisite pacing.

Endocardial left ventricular (LV) pacing for cardiac resynchronization therapy (CRT) has been proposed as an alternative to traditional LV transvenous epicardial pacing with equal or superior cardiac performance. The risks of cerebral thromboembolism and possible interference with mitral valve function moderate its clinical application.The purpose of this study was to investigate cerebral thromboembolic complications after LV endocardial lead placement. Mitral regurgitation (MR) was the secondary outcome measure.CRT candidates with a failed coronary sinus approach or nonresponders to conventional CRT underwent endocardial LV lead implantation (45 atrial transseptal, 6 transapical). Coumarin was prescribed with a targeted international normalized ratio between 3.5 and 4.5. Patient records were checked and general practitioners were contacted regarding cerebral thromboembolic complications. MR was evaluated by echocardiography at baseline and after 6 months.In 7 patients, 6 ischemic strokes and 2 transient ischemic attacks occurred, corresponding to 6.1 thromboembolic events per 100 patient-years (95% confidence interval 3.4-15.8). One patient refused hospital admission; all other patients had a subtherapeutic anticoagulation level at the time of the event. No major bleeding complications occurred. There was no change in the grade of MR (grade 2, P = .727) after 6 months.Endocardial LV lead placement in patients with advanced heart failure is associated with thromboembolic risk. However, all but 1 patient had a subtherapeutic level of anticoagulation. Endocardial LV lead placement is not associated with aggravation of MR.

Aims The femoral approach for lead extraction is typically used as a bailout procedure. We describe the results of a femoral approach with a Needle's Eye Snare and Femoral Workstation as a primary tool for extracting pacing leads. Patients and methods and results Four hundred and seventy-six pacing leads implanted for >6 months were extracted in 229 consecutive patients (178 male, age 70.4 ± 12.7 years). First, traction was performed with a standard stylet, and if unsuccessful this was followed by the femoral approach with a Needle's Eye Snare. Traction sufficed for 136 leads and a femoral approach was required in 340 leads, their respective implant times were 3.7 ± 2.9 and 9.2 ± 5.8 years. The Needle's Eye Snare failed or was only partial successful (leaving a lead remnant of

Background— Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited arrhythmia syndrome associated with mutations in the cardiac ryanodine receptor gene ( Ryr2 ) in the majority of patients. Previous studies of CPVT patients mainly involved probands, so current insight into disease penetrance, expression, genotype-phenotype correlations, and arrhythmic event rates in relatives carrying the Ryr2 mutation is limited. Methods and Results— One-hundred sixteen relatives carrying the Ryr2 mutation from 15 families who were identified by cascade screening of the Ryr2 mutation causing CPVT in the proband were clinically characterized, including 61 relatives from 1 family. Fifty-four of 108 antiarrhythmic drug-free relatives (50%) had a CPVT phenotype at the first cardiological examination, including 27 (25%) with nonsustained ventricular tachycardia. Relatives carrying a Ryr2 mutation in the C-terminal channel-forming domain showed an increased odds of nonsustained ventricular tachycardia (odds ratio, 4.1; 95% CI, 1.5–11.5; P =0.007, compared with N-terminal domain) compared with N-terminal domain. Sinus bradycardia was observed in 19% of relatives, whereas other supraventricular dysrhythmias were present in 16%. Ninety-eight (most actively treated) relatives (84%) were followed up for a median of 4.7 years (range, 0.3–19.0 years). During follow-up, 2 asymptomatic relatives experienced exercise-induced syncope. One relative was not being treated, whereas the other was noncompliant. None of the 116 relatives died of CPVT during a 6.7-year follow-up (range, 1.4–20.9 years). Conclusions— Relatives carrying an Ryr2 mutation show a marked phenotypic diversity. The vast majority do not have signs of supraventricular disease manifestations. Mutation location may be associated with severity of the phenotype. The arrhythmic event rate during follow-up was low.

Aims The maximum rate of left ventricular (LV) pressure rise (dP/dtmax) has been used to assess the acute haemodynamic effect of cardiac resynchronization therapy (CRT). We tested the hypothesis that LV dP/dtmax predicts long-term clinical outcome after initiation of CRT. Methods and results This was a retrospective observational multicentre study in 285 patients in whom dP/dtmax was measured invasively following implantation of a CRT device. The minimum required follow-up was 1 year. We analysed the relationship between dP/dtmax and time to the composite endpoint, consisting of all-cause mortality, heart transplantation (HTX), or LV assist device (LVAD) implantation within the first year of CRT. Thirty-four events occurred after a mean follow-up of 160 days (range 21–359). Patients with an event had lower dP/dtmax than patients without an event both at baseline (705 ± 194 vs. 800 ± 222 mmHg/s, P= 0.018) and during CRT (894 ± 224 vs. 985 ± 244 mmHg/s, P= 0.033), but the acute increase in dP/dtmax was similar in patients with and without an event (190 ± 133 vs. 185 ± 115 mmHg/s, P= n.s.). Left ventricular dP/dtmax-level at baseline and during CRT both predicted the clinical outcome after adjustment for gender, aetiology and New York Heart Association class: hazard ratio (HR) 0.791 [95% confidence interval (CI) 0.658–0.950, P= 0.012] and HR 0.846 (95% CI 0.723–0.991, P= 0.038), respectively. Conclusion Left ventricular dP/dtmax measured at baseline and during CRT are predictors of 1-year survival free from all-cause mortality, HTX, or LVAD implantation, but the acute improvement in dP/dtmax is not correlated to clinical outcome.

The introduction of quadripolar left ventricular pacing leadswith IS-4 4-pole standardized connectors has greatlyimproved the applicability and implementation of cardiacresynchronization therapy (CRT). Having a choice fromamong the 4 spaced electrodes, one can often avoid phrenicnerve stimulation and obtain mechanical stability in thetarget vein without compromising on optimal stimulationthreshold or location. However, there have been warnings ofissues with the hasty introduction of new standards.

In this review, the physiological rationale for atrioventricular and interventricular delay optimization of cardiac resynchronization therapy is discussed including the influence of exercise and long-term cardiac resynchronization therapy. The broad spectrum of both invasive and non-invasive optimization methods is reviewed with critical appraisal of the literature. Although the spectrum of both invasive and non-invasive optimization methods is broad, no single method can be recommend for standard practice as large-scale studies using hard endpoints are lacking. Current efforts mainly investigate optimization during resting conditions; however, there is a need to develop automated algorithms to implement dynamic optimization in order to adapt to physiological alterations during exercise and after anatomical remodeling.

A 74-year-old man with a dual-chamber implantable cardioverter defibrillator implanted 3 years before experienced multiple ventricular tachycardias (VTs). All episodes were initiated by pacemaker-mediated tachycardia (PMT) that was either stopped by atrial undersensing or the tachycardia termination algorithm of the device. After the termination of PMT, two rapid ventricular paced beats, the first initiated by artificial triggering and the second due to retrograde conduction of the first one, initiated VT that was successfully terminated by antitachycardia pacing or a direct current shock of the device. All episodes revealed this pattern of initiation with a short-long-short ventricular sequence inducing VT.

INTRODUCTION: We compared the calculated optimal V-V interval derived from intracardiac electrograms (IEGM) with the optimized V-V interval determined by invasive measurement of LVdP/dt(MAX). METHODS AND RESULTS: Thirty-two patients with heart failure (six females, ages 68 +/- 7.8 years) had a CRT device implanted. After implantation of the atrial, right and a left ventricular lead, the optimal V-V interval was calculated using the QuickOpt formula (St. Jude Medical, Sylmar, CA, USA) applied to the respective IEGM recordings (V-V(IEGM)), and also determined by invasive measurement of LVdP/dt(MAX) (V-V(dP/dt)). The optimal V-V(IEGM) and V-V(dP/dt) intervals were 52.7 +/- 18 ms and 24.0 +/- 33 ms, respectively (P = 0.017), without correlation between the two. The baseline LVdP/dt(MAX) was 748 +/- 191 mmHg/s. The mean value of LVdP/dt(MAX) at invasive optimization was 947 +/- 198 mmHg/s, and at the calculated optimal V-V(IEGM) interval 920 +/- 191 mmHg/s (P < 0.0001). In spite of this significant difference, there was a good correlation between both methods (R = 0.991, P < 0.0001). However, a similarly good correlation existed between the maximum value of LVdP/dt(MAX) and LVdP/dt(MAX) at a fixed V-V interval of 0 ms (R = 0.993, P < 0.0001), or LVdP/dt(MAX) at a randomly selected V-V interval between 0 and +80 ms (R = 0.991, P < 0.0001). CONCLUSION: Optimizing the V-V interval with the IEGM method does not yield better hemodynamic results than simultaneous BiV pacing. Although a good correlation between LVdP/dt(MAX) determined with V-V(IEGM) and V-V(dP/dt) can be constructed, there is no correlation with the optimal settings of V-V interval in the individual patient.

By current guidelines a considerable part of the patients selected for cardiac resynchronization therapy (CRT) do not respond to the therapy. We hypothesized that mechanical discoordination [opposite strain within the left ventricular (LV) wall] predicts reversal of LV remodeling upon CRT better than mechanical dyssynchrony. MRI tagging images were acquired in CRT candidates ( n = 19) and in healthy control subjects ( n = 9). Circumferential strain (εcc) was determined in 160 regions. From εcc signals we derived 1) an index of mechanical discoordination [internal stretch fraction (ISF), defined as the ratio of stretch to shortening during ejection] and 2) indexes of mechanical dyssynchrony: the 10–90% width of time to onset of shortening, time to peak shortening, and end-systolic strain. LV end-diastolic volume (LVEDV), end-systolic volume (LVESV), and ejection fraction (LVEF) were determined before and after 3 mo of CRT. Responders were defined as those patients in whom LVESV decreased by >15%. In responders ( n = 10), CRT increased LVEF and decreased LVEDV and LVESV (11 ± 6%, 21 ± 16%, and 30 ± 16%, respectively) significantly more ( P < 0.05) than in nonresponders (1 ± 6%, 3 ± 4%, and 5 ± 10%, respectively). Among mechanical indexes, only ISF was different between responders and nonresponders (0.53 ± 0.25 vs. 0.31 ± 0.16; P < 0.05). In patients with ISF >0.4 ( n = 10), LVESV decreased by 31 ± 18% vs. 5 ± 11% in patients with ISF

A 68-year-old male with heart failure and a suitable candidate for resynchronization therapy was referred to our hospital because of a failed coronary sinus (CS) lead implant. Catheterization of the CS initially also failed in our department but a left coronary angiogram revealed atresia of the CS and drainage of the coronary venous system via a persistent left superior vena cava (PLSVC). Implantation of a CS lead through the PLSVC could be accomplished after a selective angiogram, even in spite of the presence of a large thrombus at the junction of PLSVC and CS.

Background: Biventricular (BiV) pacing and left ventricular (LV) pacing both improve LV function in patients with heart failure and LV dyssynchrony. We studied the hemodynamic effect of the atrioventricular (AV) interval and the associated changes in the right ventricular (RV) electrogram (EGM) during LV pacing and compared this with the hemodynamic effect of optimized sequential BiV pacing. Methods: In 16 patients with New York Heart Association (NYHA) class II to IV, sinus rhythm with normal AV conduction, left bundle branch block (LBBB), QRS > 130 ms, and optimal medical therapy, the changes in RV EGM during LV pacing with varying AV intervals were studied. The hemodynamic effect associated with these changes was evaluated by invasive measurement of LVdP/dt max and compared with the result of optimized sequential BiV pacing in the same patient. Results: All patients showed electrocardiographic fusion during LV pacing. The morphology of the RV EGM showed changes in the RV activation that indicated a shift in the extent of fusion from LV pacing. These changes were associated with significant changes in LVdP/dtmax. Baseline LV dP/dtmax was 734 ± 177 mmHg/s, which increased to 927 ± 202 mmHg/s (Pmax. The hemodynamic effect of optimized LV pacing is equal to optimized sequential BiV pacing.

Background Variable results of cardiac resynchronization therapy (CRT) on diastolic function have been described. We investigated 3 and 12 months' effect of CRT on diastolic function and left ventricular (LV) filling pressures and their relation to LV reverse remodeling. Methods Fifty-two patients' (36 male, 69 ± 8 years, QRS duration 170 ± 29 milliseconds) echo-Doppler was performed before and 3 and 12 months after CRT. Tissue Doppler early diastolic annular (Em) and color M-mode–derived flow propagation (Vp) velocities were used to estimate LV filling pressures by E/Em and E/Vp ratios. Results After 12 months, LV reverse remodeling (end-systolic volume decrease >15%) was observed in 58%. Despite a significantly more compromised baseline diastolic function of patients without LV reverse remodeling, multivariate analysis revealed that only LV dyssynchrony could predict LV reverse remodeling. Grades 2 and 3 diastolic function improved only in LV reverse remodeling patients (from 34% to 13% to 10%), whereas a nonsignificant increase from 59% to 67% to 72% was observed in patients without reverse remodeling. Irrespective of LV volume response, short-term symptomatic benefit was related to decreased filling pressure. However, after 12 months, E/Em and E/Vp only significantly decreased in patients with LV reverse remodeling (from 16.0 ± 6 to 10.4 ± 4 and 2.2 ± 0.6 to 1.5 ± 0.4, respectively). Conclusions Left ventricular reverse remodeling induced by CRT is accompanied by improvement in diastolic function and estimated LV filling pressure. Short-term symptomatic benefit was related to decreased filling pressure. However, for longer-term symptomatic improvement and decreased filling pressures, LV reverse remodeling appeared mandatory.

Background Coronary sinus (CS) lead placement for transvenous left ventricular (LV) pacing in cardiac resynchronization therapy (CRT) has a failure rate at implant and short-term follow-up between 10% and 15%. Objective The purpose of this study was to assess the feasibility of transseptal endocardial LV pacing in patients in whom transvenous CS lead placement had failed. Methods An atrial transseptal LV lead placement was attempted in 10 patients (six females, age 69.4 ± 9.6 years), in whom CS lead placement for CRT had failed. After transseptal puncture and septal dilatation from the femoral route, the left atrium was cannulated with a combination of catheters and guide wires from the left or right subclavian vein. After advancement of this guide catheter into the LV, a standard bipolar screw-in lead could be implanted in the posterolateral wall. All patients were maintained on anticoagulant therapy with warfarin after implant. Results An LV lead could be successfully implanted in nine of the 10 patients. The stimulation threshold was 0.78 ± 0.24 V, and the R-wave amplitude was 14.2 ± 9.7 mV. At 2 months' follow-up, the stimulation threshold was 1.48 ± 0.35 V with a 0.064 ± 0.027 ms pulse width. There was no phrenic nerve stimulation observed in any of the patients. There were no thromboembolic complications at follow-up. Conclusions LV transseptal endocardial lead implantation from the pectoral area is a feasible approach in patients with a failed CS approach and in whom epicardial surgical lead placement is not an option. Longer follow-up is warranted to determine the risk of thromboembolic complications.

A 61-year-old male patient was referred for lead extraction of an infected two-chamber pacemaker system first implanted 18 years ago. A new atrial lead was implanted 9 years later because of loss of capture of the original lead. Video-assisted thoracoscopic surgery (VATS) that we use in high-risk cases showed extensive fibrous adhesion between the right atrium wall and the right lung. Dissection of the adhesion revealed the presence of an atrial lead perforated into the lung. After cutting off the lead tip, the residual lead was removed endovascularly from the subclavian site. A literature review of 25 reported cases of late atrial lead perforation was added to the findings in our case report.

I am concerned with the suggestion of Huang et al that because of their high success and low complications rates, lead extraction is preferred over abandoning nonfunctional leads at the time of device upgrade. It is not the success or complication rate that determines whether a procedure is recommendable but the net health gain for the patient. As of yet, the health profit of extracting nonfunctional leads is unproven. Even if complications are observed after leads are abandoned, this does not imply a causal relationship. Infection is not related to abandoning leads but to the surgical procedure. Venous obstruction does not suddenly result from leads that have been indwelling for years but from the insertion of new leads. Furthermore, it is unlikely that lead extraction prevents infection; it actually increases the risk by adding to the complexity of the procedure. Similarly, venous occlusion is a known complication of lead extraction, and there is no proof that the incidence is less frequent than with abandoning leads. Although the authors argue correctly that future extractions have a higher procedural risk because of longer dwell times, only a minority of patients with abandoned leads will ever need future mandatory extraction for device-related infection. Therefore, the absolute mortality and cost still will be lower than with early extraction of all nonfunctional leads. Finally, the claim that experienced centers have no extraction-related deaths is surprising. For example, The Cleveland Clinic reported 2 deaths in 429 extraction procedures of recalled leads. Thus, despite the excellent results reported by the authors, the article provides no arguments to advocate extraction of nonfunctional leads at the time of device upgrades.

Atrial tachy-arrhythmias may give rise to mode switching or noise rate reversion in dual-chamber pacemakers. In case of high amplitude of the atrial electrogram during tachycardia, a paradoxical behavior of atrial sensitivity programming can be observed. Two patients with implanted dual-chamber pacemakers showed intermittent and complete loss of atrial sensing during atrial tachycardia during device programming to a higher atrial sensitivity setting. This phenomenon is caused by amplifier ringing and can be considered as a state of amplifier saturation, which disables atrial sensing in spite of the high amplitude of the atrial signal. In patients with high amplitude of the atrial electrogram during atrial tachycardia, a paradoxical behavior of sensitivity programming resulting in atrial undersensing can be observed.

OBJECTIVE: The optimal use of pulsed wave Doppler tissue imaging (DTI) in predicting left ventricular (LV) reverse remodeling after cardiac resynchronization therapy (CRT) was investigated. METHODS: DTI was performed in 69 patients before and 3 months after CRT. Echocardiographic reverse remodeling was observed in 38 patients. LV dyssynchrony was measured with the time to onset or peak systolic velocity in 2- and 6-basal segment models. RESULTS: The time to onset and either the standard deviation of 6 segments of > 20 ms or a delay of > or = 60 ms between any 2 of 6 segments had a similar predictive accuracy (sensitivity, 97% and 95%, respectively; specificity, 74% and 73%, respectively). The time to peak systolic velocity or evaluating 2 segments was less accurate. CONCLUSIONS: Evaluation of 6 segments is necessary to predict LV reverse remodeling after CRT. The time to onset of systolic velocity is superior to the time to peak velocity.

This study investigated the optimal echocardiographic indexes to determine the most hemodynamically appropriate atrioventricular (AV) delay in cardiac resynchronization therapy (CRT) for heart failure. Doppler echocardiographic optimization of AV delay in CRT has not been correlated with invasive hemodynamic indexes. In 30 patients who underwent CRT, invasive left ventricular (LV) pressure measurements with a sensor-tipped pressure guidewire and Doppler echocardiographic examination were performed24 hours after pacemaker implantation. Invasively, the optimal sensed AV delay was determined by LV dP/dt(max). The Doppler echocardiographic methods evaluated were the velocity-time integral (VTI) of the transmitral flow (EA VTI), diastolic filling time (EA duration), the VTI of the LV outflow tract or aorta (LV VTI), and Ritter's formula. Biventricular pacing with optimized interventricular and AV delay increased LV dP/dt(max) from 777 +/- 149 to 1,010 +/- 163 dynes/s (p0.0001). The optimal AV delay with the EA VTI method was concordant with LV dP/dt(max) in 29 of 30 patients (r = 0.96), with EA duration in 20 of 30 patients (r= 0.83), with LV VTI in 13 patients (r = 0.54), and with Ritter's formula in none of the patients (r = 0.35). In conclusion, to obtain the optimal acute hemodynamic benefit of CRT, Doppler echocardiography is a reliable tool to optimize the AV delay compared with the invasive LV dP/dt(max). The measurement of the maximal VTI of mitral inflow is the most accurate method.

VAN GELDER, B.M., ET AL.: The Effect of Anodal Stimulation on V-V Timing at Varying V-V Intervals. We studied the effect of anodal capture at the ring electrode of the right ventricular (RV) lead on interventricular (V-V)timing during biventricular (BiV) pacing, in which left ventricular (LV) pacing was preceding RV pacing. The V-V interval was programmed from 80 to 4 ms (LV first) in the LV unipolar (LV tip-generator can) followed by the LV tip-RV ring pacing configuration. In the LV unipolar configuration, V-V programming leads to a continuous change in morphology of the QRS complex according to a change in collision of both activation fronts. When using the LV tip-RV ring configuration with anodal capture at the RV ring electrode no change in QRS morphology was recorded varying the V-V interval from 80 to 60 and 40 ms. However, at V-V intervals between 20 and 4 ms a change in morphology of the QRS complex was recorded, which was due to additional cathodal stimulation of the RV tip electrode during RV stimulation.

The aim of this study was to determine the effect of patient and lead characteristics on occlusion of the access vein in pacemaker and ICD patients. Contrast venography of the access vein was obtained in 89 patients (17 patients with an ICD) scheduled for lead extraction. The indication for extraction was infection in 57 patients (systemic infection in 9) and lead malfunction in 32 patients. In 6 of the 89 patients, leads were introduced in both the right and left subpectoral area, resulting in a total of 95 venous entry sites. In 22 of these entry sites one lead was present, in 61 two leads, in 11 three, and in 1 four leads. The vessel patency was graded open or occluded. Occlusion of the subclavian vein occurred in four (13%) patients with lead malfunction versus 18 (32%) patients with infection (P = 0.07). In patients with systemic infection, 5 of 9 showed venous occlusion (P = 0.01 when compared to patients with malfunction, odds ratio 8.75, 95% confidence interval 1.21-64.11). Considered per entry site, the incidence of occlusion was 7 of 22 with one lead present, 17 of 61 with two leads, 0 of 11 with three leads, and 0 of 1 with four leads (P = 0.13). No patient had a superior vena caval occlusion. Patients with systemic infection have an increased risk of occlusion of the access vein. On the contrary, the study found no support for the concept that the risk of venous occlusion increases with a higher number of leads present.

We describe the extraction of a pacing lead via the femoral artery 5 months after it was inadvertently introduced through the right subclavian artery and positioned in the left ventricle. The lead was dislocated from the myocardium by traction from the subpectoral area and subsequently removed with a retriever inserted through the femoral artery in order to minimize the risk of cerebral embolization and bleeding at the entry site. Bleeding was controlled at the subclavian artery entry site by temporary inflation of a balloon catheter inserted through the brachial artery, and at the insertion site of the retriever in the femoral artery with a closure device.

Chronically implanted ventricular pacing and defibrillator (ICD) leads can adhere to the tricuspid valve. This study examined the effect of lead extraction, and laser sheath extraction in particular, on tricuspid valve regurgitation. Lead extraction was first tried with traction using limited force followed by a laser sheath if not successful. Tricuspid valve regurgitation before and after extraction was evaluated with transesophageal echocardiography and graded from 0 (none) to 4 (severe). A change in regurgitation was considered clinically relevant if it increased with two grades or more and resulted in at least grade 3 regurgitation. Fifty ventricular leads were extracted in 43 consecutive patients, including 14 ICD leads. In 20 patients (group I) leads were removed without a (laser) sheath crossing the tricuspid valve, in 23 patients (group II) leads were extracted with lasing across the valve. The mean time from implant was 43 +/- 43 months and 99 +/- 78 months, respectively, (P = 0.007). Tricuspid regurgitation increased in five (12%) patients. In group I only in one patient the laser failed proximal of the valve and forceful traction was subsequently used, and in group II this occurred in four (17%) patients. This difference did not reach statistical significance even excluding the patient from group I (P = 0.111). The increase of tricuspid regurgitation cautions against indiscriminate extraction of superfluous leads. There is a trend that when tools like a laser sheath are necessary the chance of tricuspid valve damage increases.

We studied the acute hemodynamic effect of left ventricular (LV) pacing from a dual cathodal coronary sinus (CS) lead in a both single- and dual-site electrode configuration.In 17 patients who underwent implantation of a cardiac resynchronization therapy-defibrillator system with dual cathodal CS leads, LV stimulation was performed from the distal and proximal electrode separately and from both electrodes simultaneously. The acute hemodynamic response was evaluated by invasive measurement of LVdP/dtmax. Timing of LV electrical activation time measured from onset QRS to LV sense during intrinsic rhythm at both electrodes were determined from simultaneous intracardiac recordings. The latter results were compared to those of an additional group of 26 patients in whom no hemodynamic effects were evaluated.Baseline LVdP/dtmax was 897 ± 222 mm Hg/s. Single-site LV pacing resulted in a rise of LVdP/dtmax to 1,053 ± 266 mm Hg/s (+17.4%) taking the best of the two sites and 1,020 ± 254 mm Hg (+13.7%) at the worst site (P = 0.0001). In the dual-site pacing configuration LVdP/dtmax was 1,026 ± 243 mm Hg/s (+14.1%). P value for single best versus dual site was 0.005, and for dual site versus worst single site was 0.18 (n.s.).Even with a relatively small distance of 20-21 mm between stimulation electrodes, there is a significant difference in acute hemodynamic effect from the single best and worst site. Dual-site LV pacing offers no hemodynamic benefit over the best single pacing site. The short electrode distance may have been a limitation and results may not be applicable to other forms of multisite pacing.

A 50-year-old male underwent a mechanical tricuspid and mitral valve replacement after ventricular septum rupture because of an inferior wall infarction, followed by implantation of a dual chamber pacemaker (Medtronic Adapta ADDRL1; Medtronic Inc, Minneapolis, MN) for complete heart block. Because of the mechanical tricuspid valve ventricular pacing was accomplished by a Medtronic 4194 lead placed in a posterior branch of the coronary sinus (CS). An implantable cardioverter defibrillator (ICD) implantation was scheduled because of an ejection fraction of 29% after a previous myocardial infarction, The New York Heart Association class III, and development of nonsustained ventricular arrhythmias. Owing to the presence of the mechanical tricuspid valve, we preferred to implant a subcutaneous …

A 45-year-old male had a VVI pacemaker implanted 20 years ago because of complete heart block. Because of perforation of the lead the pulse generator was removed after 4 weeks and a second lead was implanted from the contralateral side. Recently, the patient presented with symptoms of lightheadedness and syncope associated with prolonged pauses in the electrocardiogram. From the ECG, the ECG interpretation channel, and intracardiac electrogram telemetry, it was concluded that the VVI pacemaker was inhibited by P waves. The most likely explanation for this phenomenon was an insulation defect in the functioning lead caused by friction with the abandoned lead at the level of the high right atrium.

Dislodgment of the coronary sinus lead was observed in a 79-year-old patient 8 months after implantation of a biventricular pacing system. A severe stenosis in the posterolateral branch, in which the lead was previously positioned, prohibited reinsertion of the lead. Because no other branches with adequate anatomy for lead insertion were available in the targeted area, the stenosis was dilated and stented. Subsequently, the left ventricular lead could be reimplanted in the same vessel.

Intubation of the coronary sinus failed during implantation of a biventricular pacing system. An angiogram of the left coronary artery showed in the venous phase a coronary sinus not communicating with the right atrium. The coronary sinus was draining into a persistent left superior vena cava communicating with the left subclavian vein. The coronary sinus lead was successfully implanted through the persistent left superior vena cava, whereas the atrial and ventricular leads were implanted through the right superior vena cava in a conventional way.

To the Editor: We read with interest the article by Thibault et al1 comparing the effect of left ventricular (LV) pacing versus simultaneous biventricular pacing, a study with a crossover design between both pacing modes. Submaximal exercise was used as an elegant method of qualification of the clinical response. The optimal atrioventricular intervals (atrial sensed-ventricular paced and atrial paced-ventricular paced) were determined during LV pacing and defined as the longest atrioventricular interval that fully captured the ventricle (no fusion with intrinsic conduction). This atrioventricular delay was used for LV and biventricular pacing, along with the rate-adaptive atrioventricular delay feature, and was …

A 76-year-old male had dual-chamber implantable cardioverter defibrillatorimplanted, employing a Medtronic Sprint Fidelis 6931-65 shock. A routine follow-up 4 years later showed a sudden steep decrease in the amplitude of the right ventricular electrogram (EGM) from 9.0 to 2.0 mV ( Panel A ). Because of the known high failure rate related to the Sprint Fidelis shock lead, we initially focused on markers of lead failure by recordings of the intracardiac EGM, changes in …

Introduction The European Heart Rhythm Association charged the present writing committee with the task of producing a consensus document on training and accreditation for transvenous extraction of chronically implanted pacing and defibrillator leads.1,2 The core curriculum for the European Heart Rhythm Specialist includes implantation of heart rhythm devices but does not specifically mandate learning and accreditation for extraction techniques.3 The lack of such recommendations is related to the limited number of extractions available for training purposes and attaining competency. The present document focuses on the rising burden and the increasing complexity of techniques of lead extraction with an emphasis on the critical issues of training, accreditation, and documentation of results. There is also an educational component felt necessary to include by the Task Force in view of the specialized and emerging nature of this field. Where appropriate, a European perspective is presented and paediatric aspects are treated separately. The aim is to complement two recently published documents, one from the Heart Rhythm Society (HRS)4 on facilities, training, indications, and management of transvenous lead extraction and the other from the American Heart Association on device-related infections.5 The indications for lead extraction have not changed since these publications and are therefore not covered in this present document. ### Need for lead extraction/removal—a European perspective Due to improving recognition of clinical need and wider indications, the implant rate of Cardiovascular Implantable Electronic Devices (CIED) continues to rise in most countries.6,7 The number of leads per patient is increasing with cardiac resynchronisation therapy–pacemaker/defibrillator, upgrades and a higher proportion of dual vs. single-chamber devices. As life expectancy has risen, so have the number of generator and lead changes despite advances in technology. Product advisories are inevitable despite overall improvements in reliability and have led to surges in extraction.8–10 Currently, infection accounts …

The maximum rate of left ventricular (LV) pressure rise (dP/dt(max)) has been used to assess the acute haemodynamic effect of cardiac resynchronization therapy (CRT). We tested the hypothesis that LV dP/dt(max) predicts long-term clinical outcome after initiation of CRT.This was a retrospective observational multicentre study in 285 patients in whom dP/dt(max) was measured invasively following implantation of a CRT device. The minimum required follow-up was 1 year. We analysed the relationship between dP/dt(max) and time to the composite endpoint, consisting of all-cause mortality, heart transplantation (HTX), or LV assist device (LVAD) implantation within the first year of CRT. Thirty-four events occurred after a mean follow-up of 160 days (range 21-359). Patients with an event had lower dP/dt(max) than patients without an event both at baseline (705 ± 194 vs. 800 ± 222 mmHg/s, P= 0.018) and during CRT (894 ± 224 vs. 985 ± 244 mmHg/s, P= 0.033), but the acute increase in dP/dt(max) was similar in patients with and without an event (190 ± 133 vs. 185 ± 115 mmHg/s, P= n.s.). Left ventricular dP/dt(max)-level at baseline and during CRT both predicted the clinical outcome after adjustment for gender, aetiology and New York Heart Association class: hazard ratio (HR) 0.791 [95% confidence interval (CI) 0.658-0.950, P= 0.012] and HR 0.846 (95% CI 0.723-0.991, P= 0.038), respectively.Left ventricular dP/dt(max) measured at baseline and during CRT are predictors of 1-year survival free from all-cause mortality, HTX, or LVAD implantation, but the acute improvement in dP/dt(max) is not correlated to clinical outcome.

Aims Coronary sinus (CS) lead placement for transvenous cardiac resynchronization therapy (CRT) even combined with transseptal left ventricular (LV) endocardial implantation from a superior approach still does not have 100% success rate. The aim of this study was to assess the feasibility of a femoral transseptal endocardial LV approach pacing in patients in whom a transvenous CS or a transseptal LV endocardial implantation with a superior approach had failed. We report our first experience with LV endocardial lead placement for CRT with a femoral transseptal technique followed by intravascular pull-through to the pectoral location. Methods and results In 11 patients, 10 males (61.5 ± 9.5 years) with failed CS implant (four patients) or repeated CS lead malfunction (seven patients), a 4.1 French active fixation lead was implanted endocardially in the left ventricle employing a femoral approach using an 8F transseptal sheath combined with a hooked 6F catheter. After successful implantation, the lead was pulled through from the femoral insertion site to the pectoral device location. The LV endocardial implantation was successfully performed in all patients. Stimulation threshold was 0.62 ± 0.33 V, lead impedance 825 ± 127 Ω, and R wave 12.8 ± 8.3 mV. Threshold and lead impedance were stable during follow-up, which varied from 1 to 6 months. No dislodgements were observed and there were no thrombo-embolic events during follow-up. Conclusion This technique for LV endocardial lead implantation is an alternative for failed CS and superior transseptal attempts using standard techniques and equipment. It is also applicable for pacing sites that are more easily reached from a femoral approach.

Cardiac resynchronization therapy (CRT) has become an important treatment for patients with heart failure and left ventricular dyssynchrony (Cazeau et al., 2001; Abraham et al., 2002; Auricchio et al., 2002; Cleland et al., 2005). For left ventricular (LV) pacing in CRT, transvenous placement of a lead into one of the posterolateral tributaries of the coronary sinus (CS) is the first choice. However, even with growing experience and improvement of available materials and tools placement of a lead into the coronary venous system may fail. Failures can be due to inability to engage the coronary sinus, absence of suitable side branches in the posterolateral area, coronary vein stenosis, lead instability, high stimulation threshold, phrenic nerve stimulation or a combination (Auricchio et al., 2004; Bentkover et al., 2003; Gras et al., 2002). As alternative for surgical epicardial lead implantation, in case of failed coronary sinus implant, atrial transseptal approaches with endocardial LV lead placement have been described, using a modified transseptal puncture technique from either the right jugular vein (Jais et al., 1998; Jais et al., 2000; Leclercq et al., 1999; Jais et al., 2006) or from the left axillary vein (Sen et al., 2004). We modified the atrial transseptal technique for endocardial LV lead placement by using a standard transseptal puncture from the femoral vein, dilatation of the atrial septum and subsequent passage of the lead through the septum via the subclavian vein (Van Gelder et al., 2007). Shortly after, a second alternative technique was described for LV endocardial implantation, using a limited lateral thoracotomy with transapical insertion of the lead (Kassai et al., 2009). We also used this transapical technique in a number of patients in whom the trans-atrial septum implant was unsuccessful or contraindicated due to the presence of an artificial valve in mitral position. Besides being an alternative for failed coronary sinus implants, the flexibility of lead positioning by both endocardial techniques also offers the possibility of an endocardial implant at a different LV site in patients not responding to CRT. The efficacy of the

We developed a U-shaped diagnostic and guiding catheter for left coronary angiography and angioplasty. Angiography with a 6 French (F) diagnostic U-shaped catheter was attempted in 101 patients (pts). Primary use in 82 pts; all successful. Secondary use after failure of 6 F left Judkins diagnostic catheters to intubate the left main coronary artery in 19 pts; 17 successful. An 8 F U-shaped guiding catheter was used for percutaneous transluminal coronary angioplasty (PTCA) of left coronary artery branches in 102 pts [left anterior descending (LAD), 48 pts; circumflex (CX), 54 pts]. Stable cannulation of the left coronary artery was achieved in 96 pts (94%), but PTCA was successful in 90 pts (88%). Primary use in 70 pts (LAD, 27 pts; CX, 43 pts). PTCA was successful in 60 pts. Secondary use after failure of left Judkins and Amplatz guiding catheters in 32 pts (LAD, 21 pts; CX, 11 pts). PTCA was successful in 30 pts. No complications were seen. In conclusion, U-shaped diagnostic and guiding catheters increased the success rate of (1) left coronary angiography after failure of left Judkins diagnostic catheters; and (2) PTCA of the left anterior descending and circumflex arteries after failure of left Judkins and Amplatz guiding catheters © 1993 Wlley-Liss, Inc