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).