Abstract 5924: Epicardial vs. Coronary Sinus Lead Placement for Cardiac Resynchronization Therapy in the Treatment of Heart Failure
Introduction: Left ventricular (LV) epicardial (EPI) leads are commonly used after failure to place coronary sinus (CS) leads in cardiac resynchronization therapy (CRT) and have been postulated to be advantageous with fewer of the anatomic limitations inherent to CS leads. We aimed to determine whether EPI placement is associated with superior outcomes when compared to CS placement in patients undergoing CRT.
Methods: Patients who underwent CS lead placement attempts for CRT were identified from a prospectively collected clinical database. Those who failed CS lead placement and subsequently underwent minimally invasive LV EPI lead placement were compared to patients with successful CS lead placement. Clinical, electrocardiographic, and echocardiographic data were collected. Data were analyzed using a parametric hazard model and propensity analysis.
Results: CRT devices were placed in 482 patients (74% male, mean age 67 years, 64% ischemic cardiomyopathy, LV ejection fraction (EF) 19.3±7.2%, QRS duration 176±28 ms). CS leads were successfully placed in 360 pts (75%) and 122 (25%) patients had EPI placement. ICDs were placed in 68% and pacemakers in 32%. Baseline age, sex, history of MI, diabetes, NYHA class, ACE inhibitor use and baseline QRS were similar in both groups. Propensity modeling showed EPI patients were more likely to receive an ICD, have less tobacco use, more β-adrenergic blocker use and higher baseline EF. For the longitudinal repeated measurements analysis of EF and QRS duration, there were no differences between EPI and CS leads in EF (p=.5), percent change in EF (p=.75), QRS (p=.08) or change in QRS duration (p=.22). Baseline EF (p<.001) and QRS duration (P<.001) correlated with EF and QRS at follow-up, respectively. Results were similar after adjusting for propensity score. Survival analysis using a parametric hazard model showed no difference in mortality between groups, including after adjustment for the propensity score.
Conclusions: Compared to CS leads, minimally invasive LV epicardial leads used for CRT appear to have a similar effect on EF, QRS duration and survival. LV epicardial leads are an acceptable alternative to CS leads for CRT in heart failure patients but were not associated with superior outcomes compared to CS leads.