Provocative Cases -> Teaching Case Reports D-PO04 - Poster Session IV (ID 15) Poster

D-PO04-028 - Left Ventricular Lead Inability To Capture Due To Epicardial Fat (ID 411)

 M. Shehadeh: Nothing relevant to disclose.


Background: Left ventricular (LV) lead implantation challenges can often be overcome by utilizing a variety of tools and techniques, some adapted from interventional cardiology. We present two patients with unsuccessful LV lead implantation secondary to elevated lead capture thresholds, despite pacing from multiple coronary sinus branches. Both patients were found to have thick epicardial fat.
Objective: To illustrate that epicardial fat might interfere with transvenous LV lead capture and to suggest possible alternative interventions in such patients to achieve resynchronization.
Methods: Two elderly female patients with a medical history of obesity (BMI 33 and 45) and symptomatic atrial fibrillation underwent atrioventricular node ablation with biventricular pacemaker implantation. During the procedure, coronary sinus venography was performed, and the LV lead was able to be advanced into multiple posterolateral branch options. Pacing thresholds were tested from different sites.
Results: The LV lead capture threshold was extremely high (5 to 8V) from different sites. The LV leads were deactivated to avoid premature generator cell depletion. Cardiac computerized tomography imaging was performed postoperatively and confirmed the presence of interfering epicardial fat pad as thick as 7.5 mm.
Conclusion: Epicardial fat can enhance local inflammation and predispose to arrhythmia, especially atrial fibrillation. This case series demonstrates that epicardial fat might interfere with transvenous LV lead capture. To achieve successful resynchronization in such patients, conduction system pacing such as His Bundle or Left Bundle Branch pacing can be considered.