Cardiac Resynchronization Therapy - Lê Thanh Liêm

Ts.Bs. Lê Thanh Liêm 
Cho Ray hospital 
CRT implantation at Cho Ray hospital 
[PERCENTA
GE] 
4% 
5% 
2% 
Heart failure + LBBB
Heart failure + Non-LBBB
 Starting from 2008 
 10 cases/year 
 Total CRT implatation # 80 
CRT implantation at CR hospital 
 Longest implantation time: 7h (cannot withdrawn guidewire 
because of tortuously venous -> repeating 3 times) 
 Shortest implantation time: 1h30. 
 Succesful rate at the first operation: 97,3% 
 Succesful rate at the second operation: 100% 
CRT implantation at CR hospital 
 Response rate after CRT: #90% 
 Reason for stoping first operation: 
 Coronary venous dissection: 1 case 
 Cannot canulating CS os: 1 case 
 Hematoma: 1 case 
 LV lead dislogement: 1 case 
 Inapropriate shock: 3 case 
 LV lead lost capture: 2 cases 
Infection complication 
Nhiễm 
trùng dây 
Nhiễm 
trùng túi 
máy 
Sốt không 
rõ đường 
vào 
LOẠI NHIỄM TRÙNG 
Bảo tồn 
Rút bỏ hệ 
thống 
máy(khôn
g thể bảo 
tồn) 
ĐIỀU TRỊ NHIỄM 
TRÙNG 
 Bệnh nhân ở Khánh Hòa, đặt máy CRT-D, sau đặt máy, lâm sàng cải thiện 
tốt, bệnh nhân gắng sức tốt, đi biển đánh cá lại bình thường -> bỏ tái khám. 
Sau 3,5 năm, bệnh nhân bị nhiễm trùng túi máy, bào mòn túi máy và lộ máy 
-> tháo bỏ hệ thống máy 
Infection complication 
40% 
40% 
20% 
Result 
CRT restore
CRT extract
Death before CRT extract
Results of Infection complication 
Mortality ratio and Sudden Death 
Tử vong 
15% 
[CATEG
ORY 
NAME] 
[PERCE
NTAGE] 
Tỉ lệ tử vong cộng dồn sau 8 
năm 
Tử vong 
Còn sống 
Viêm phổi 
18% 
Suy tim tiến 
triển 
37% Đột tử 
18% 
Thuyên tắc 
phổi 
9% 
K phổi 
9% 
Suy thận mạn 
9% 
Nguyên nhân 
Viêm phổi 
Suy tim tiến triển 
Đột tử 
Thuyên tắc phổi 
K phổi 
Suy thận mạn 
Difficulties of CRT implantation at 
CR Hospital 
1. Cannot canulate CS. 
2. Cannot advance the pacing lead into one of CS 
tributaries. 
3. LV lead dislogement during procedure or during slitting 
catheters. 
4. LV lead lost captures 
5. Nonresponder 
1. Cannot canulate CS - anatomy 
1. Cannot canulate CS - anatomy 
1. Cannot canulate CS - anatomy 
Cannot canulate CS 
Reasons: 
Thebesian valve. 
 small diameter 
 Tortuously venous 
Coronary venous angiography 
 Easy to approach tributaries 
Coronary venous angiography 
 Easy to approach tributaries 
1. Cannot canulate CS 
Coronary venous angiography 
 Only one big branche, but it’s tourtuously 
Coronary venous angiography with 
straight venous 
 Venous branche is so straight 
Coronary venous angiography with very 
small CS system 
 Unsucceed at the first implantation after 4h 
 Reimplanting, combine two 3D MP catheter => succeed. 
Coronary venous angiography with very 
small CS tributaries 
Coronary venous angiography with very 
small CS tributaries 
 Before nitrate 
Coronary venous angiography with very 
small CS tributaries 
 After nitrate 
Coronary venous angiography with very small venous and 
thebestian valve and very small tributaries 
 After interventing venous branche with balloon to dilate 
diameter and inserting a 4F lead-> succeed 
2. LV lead dislogement during procedure or 
during slitting catheters. 
 Before slitting MP 
2. LV lead dislogement during procedure or 
during slitting catheters. 
 After slitting MP 
2. LV lead dislogement during 
procedure or during slitting catheters. 
Reason and solution 
No steady slitting hand when slitting 
catherters: keeping steady. 
Not enough support: stiffer guidewires 
Straighly venous branches: increasing 
diameters of LV lead, LV lead with new 
shapes or srew LV lead 
2. Pacing lead lost captures 
Make chest Xray, echo and ECG 
Hingher threshold: increasing output, pulse 
width, changing pacing vectors, check 
arrythmias drugs. 
Changing position of LV lead: reimplanting 
Plugging pacing lead incorrectly: plug again 
Leakage blood inside conneting port: 
Lead rupture: changing 
LV lead lost capture after 3weeks of 
Amiodarone 
 Very wide QRS duration. Hypotension (70/40 with dopamin) 
 Lost LV threshold: lost capture 
 Lost LV capture 8/10 vectors (at implantation 10 vectors had 
been captured) 
LV lead capture again after pacing vector 
changing 
 Changing LV pacing vector 
 LV capture again, narrower QRS 
 Blood pressure increase from 70/40 to 110/70 and discharge 1 day after changing LV 
pacing vector. 
 Check again after 7 days(telephone): good status, no symptom 
LV lost capture 
 LV lost capture after 4 months. 
 LBBB again on ECG 
 No capture again with 10 vector changing 
LV capture again after changing position of 
LV lead 
 ECG after changing LV position 
 Good LV threshold 
 Narrower QRS 
Thank you 
for your 
listening