Novel Approach for Transbaffle Puncture for Transvenous-Transarterial Pacemaker System Placement in Adult Patient with Extracardiac Non-fenestrated Fontal Conduit
Presenter
Bayan Issa, M.D., University of Iowa Stead Family Children’s Hospital, Iowa City, IA
Bayan Issa, M.D., Benjamin Hale, MD, Ian H Law, M.D. and Osamah Aldoss, M.D., FSCAI, University of Iowa Stead Family Children’s Hospital, Iowa City, IA
Keywords: Adult Congenital Heart Disease (ACHD)
Title Novel Approach for Transbaffle Puncture for Transvenous-Transarterial Pacemaker System Placement in Adult Patient with Extracardiac Non-fenestrated Fontal Conduit. Introduction Patients with single ventricle physiology who underwent Fontan palliation have a high rate of pacemaker implantation, up in 9.2%. For patients with extracardiac Fontan conduit, transvenous atrial leads are not usually feasible, as there is no atrial tissue in the venous Fontan circuit. For patients needing ventricular pacing, a transbaffle approach to access the arterial circulation is needed if endocardial ventricular pacing is desired. Here, we report a novel approach to transbaffle puncture to allow for dual chamber endocardial pacemaker implantation in an extracardiac Fontan patient with multiple failed epicardial leads. Clinical Case A 19-year-old patient with history of D-transposition of the great arteries (D-TGA), double inlet left ventricle (DILV), subpulmonic stenosis and ventricular septal defect. Patient underwent the final stage of palliation with an extracardiac Fontan with an 18mm Gore-tex tube graft at 5 years old with patch closure of the right ventricular atrioventricular valve (tricuspid valve). Her surgery complicated with complete heart block that required epicardial right atrial and right ventricular (RV) leads placement with abdominal generator. The RV lead failed and required replacement at 18 years old, however the new RV lead rapidly developed high pacing threshold and non-capture necessitating replacement within 4 months. After extensive discussion, the decision was made to proceed with placement of transvenous-transarterial system with leads in the systemic atrium and ventricle via transpulmonary atrial puncture. An attempted access from left subclavian vein using radiofrequency (RF) energy to perforate through the LPA into the atrium was not successful due to inability to engage the desired puncture site. Another attempt to access the common atrium was successful via a right internal jugular approach using Versacross sheath and RF energy applied to a J-wire. To transfer the wires to the left subclavian vein, balloon angioplasty using 6 mm x 4 cm Opta Pro balloon catheter of the tract was performed. At the same time, a glide catheter and glide wire were advanced to the puncture site from the left subclavian vein, and the wire was passed into the atrium as the balloon deflated. Once wire access to the RV was obtained, a long sheath was advanced from left subclavian vein and two wires were passed through the tract, which were used to implant atrial and ventricular pacemaker leads. Discussion Our case describes a unique technique for endocardial pacemaker lead placement in patients with extracardiac non-fenestrated Fontan system. This case shows that an endocardial pacing system via transbaffle puncture is feasible and can be considered if epicardial leads are not a good option.