Discussion:
Venous occlusion is a well described complication after transvenous lead placement with an estimated incidence of 20 to 26% depending on the time since implantation (2,3). Balloon venoplasty and laser lead extraction techniques have been developed to overcome these occlusions but carry with them inherent procedural risks, additional expense and need for specialist training. Whilst retrograde contrast injections to define a venous stenosis has previously been described, its use has been to facilitate bypassing a stenosis with guidewires and ultimately performing venoplasty to allow percutaneous trans-venous lead placement (4). We believe this is the first description of direct percutaneous venous puncture using this technique, avoiding the need for venoplasty or laser lead extraction, thereby lowering procedural risks.
PIC has been estimated to occur in 10-20% of individuals with normal baseline LV function receiving a high RV pacing burden (5). RV pacing results in electrical and mechanical dyssynchrony (6) and chronic RV pacing is associated with an increased risk of heart failure, atrial fibrillation and death (7).
Compared to RV pacing, CRT with biventricular pacing (BVP) improves dyssynchrony, however, it does not restore normal ventricular activation (8,9). HBP enables ventricular activation through the direct stimulation of the His-Purkinje system. This expanding technique results in more physiological ventricular contraction when compared to BVP (8) with reassuring safety and longer-term outcomes (10).
To reduce the risk of PIC the latest ACC/AHA pacing guideline give HBP a class IIa recommendation in patients undergoing pacemaker implantation for AV block, with mild -moderate LV impairment (LVEF 36 to 50%) with an expected RV pacing burden > 40% (1).