Simultaneous Axillary Venous Access for Pulmonary Artery Pressure Monitor and Biventricular Defibrillator Implantation

Introduction

The CardioMEMS HF system (Abbott) provides ambulatory monitoring of pulmonary artery pressures and reduces hospitalization for heart failure. Cardiac resynchronization therapy is indicated for patients with heart failure, cardiomyopathy, and a left bundle branch block on electrocardiography. While the CardioMEMS is typically implanted via a femoral venous sheath, we describe implantation via the axillary vein at the time of biventricular defibrillator implantation.

Case Description

A 77-year-old man with hypertension, hyperlipidemia, diabetes mellitus, and chronic renal insufficiency (creatinine 1.6 mg/dL) presented with heart failure and dilated cardiomyopathy with an ejection fraction of 20%. He was treated at an outside medical center for heart failure exacerbation and discharged without a workup for ischemia. He had some nonsustained ventricular tachycardia and had been wearing a LifeVest Wearable Defibrillator (ZOLL Medical) for the previous 4 months. During this time, he symptomatically improved with medical therapy, including hydralazine, nitrates, and carvedilol, doses of which were limited by low systolic blood pressures. An ECG demonstrated sinus rhythm with a left bundle branch block and premature ventricular contractions. Repeat echocardiography at 4 months confirmed an ejection fraction of 20%. He was referred for coronary angiography with CardioMEMS implantation, with a possible biventricular defibrillator to follow. He was offered the opportunity to have these procedures completed in the same session, and he agreed. 

Procedure

The patient was prepped separately for right transradial coronary angiography. This was performed with a GLIDESHEATH SLENDER 6 French (Terumo Medical Corporation), and end-hole 5 Fr JL4 and JR4 catheter inserted to perform coronary angiography with a biplane fluoroscopy system at 10-inch magnification. Left coronary artery angiography showed nonobstructive coronary disease (Figures 1 and 2), and levophase angiography demonstrated a large coronary sinus and suitably-sized posterolateral branch for the left ventricular lead (Figure 3). Right coronary angiography showed diffuse disease with up to 80% stenosis in the posterior descending (Figure 4); however, these were not felt to adequately explain the patient’s cardiomyopathy. A total of 16 ml of contrast was used for coronary angiography. These lesions were deferred for later intervention given the risks of additional contrast exposure and need for anticoagulation, which would preclude device implantation. Hemostasis of the transradial site was obtained with a TR BAND (Terumo Medical Corporation). No anticoagulation was administered.

The sterile draping for the coronary angiogram was taken down and the left chest was prepped for device implantation. Using real-time ultrasound guidance, three 0.035” guidewires were inserted percutaneously into the left axillary vein. A device pocket was created, and the 3 wires pulled through to exit the pocket. A figure-of-eight suture was placed around the wires for hemostasis following sheath insertion (Figure 5).

A 12 Fr sheath was inserted over the wire and used to insert a 7 Fr pulmonary artery catheter (PAC). This was used to obtain right heart pressures and pulmonary artery samples for oximetry. A 0.018” Platinum Plus guidewire (Boston Scientific) was inserted through the PAC into the left pulmonary artery and used to advance the PAC to a segmental branch (Figure 6). Four milliliters of diluted contrast were manually injected for pulmonary arteriography, which showed a posteriorly (vertically) directed branch (Figure 7). 

The CardioMEMS delivery catheter was inserted over this wire. We encountered some minor anatomic challenges as the straight delivery catheter tended to come out of the superior vena cava towards the inferior vena cava and pull the guidewire back. This was addressed by reducing magnification to image the catheter in the right atrium and pulmonary artery, advancing and obtaining more guidewire purchase in the pulmonary artery, and then holding tension on the guidewire while advancing the delivery catheter (Figure 8). The CardioMEMS was released over the third anterior rib (Figure 9). However, as the looped guidewire was retracted, it snared the device and pulled it back to the proximal left pulmonary artery (Figure 10). Fortunately, it was easily repositioned by readvancing the guidewire loop through the PAC (Figure 11), with a plan to use the PAC balloon to push the device forward if needed. Pulmonary artery pressures were remeasured and correlated with the CardioMEMS device measurement.

Defibrillator lead implantation was straightforward, with an 8 Fr SafeSheath (Pressure Products) used for the right ventricular lead and 6 Fr for the right atrial lead. The 12 Fr sheath was removed over a Magic Torque 0.035” guidewire (Boston Scientific) and used to insert a 9 Fr coronary sinus (CS) guide catheter (CPS Direct, Abbott). Hemostasis around the smaller guide was obtained by tightening the figure-of-eight suture. The CS guide was inserted into the coronary sinus using a 5 Fr AL1 diagnostic catheter. A quadripolar coronary sinus lead was inserted to the posterolateral branch over a RUNTHROUGH (Terumo Medical Corporation) 0.014” guidewire without difficulty and without the need for coronary sinus venography (Figure 12). The leads were attached to a device, hemostasis was obtained and the figure-of-eight suture was tied, and the device was implanted with a TYRX Absorbable Antibiotic Envelope (Medtronic). The patient was observed for 6 hours and discharged with oral antibiotics, pain medication, aspirin, and clopidogrel for the CardioMEMS device. At 1-week follow-up, he reported improvement in his exercise tolerance and no complications (Figure 13).

Discussion

The CardioMEMS HF system utilizes a miniaturized pressure sensor placed in the pulmonary artery that provides intermittent at-home monitoring of pulmonary artery pressures. It is indicated for New York Heart Association Class III patients who have been hospitalized in the previous year. In the setting of a comprehensive heart failure program and close follow-up, the CardioMEMS system reduced heart failure admissions by 33% in the randomized CHAMPION study.¹ Real-world Medicare claims data have supported a 45% reduction in heart failure admissions in patients with this device.² Most recently, a post-approval prospective study indicated that patients with the device were 58% less likely to have a heart failure hospitalization than in the year prior receiving the device.³

The CardioMEMS sensor is typically implanted through the femoral vein. The internal jugular approach has also been used and may result in reduced implantation times and a higher likelihood of same-day discharge.⁴ To our knowledge, this is the first report of implantation through the subclavian vein at the same time as a cardiac implantable electronic device. 

In this case, implantation of both the CardioMEMS and biventricular defibrillator through the left axillary and subclavian veins has the benefit of a single access site, potentially reducing bleeding and discomfort. Many patients with cardiomyopathy and indications for CRT are NYHA Class III and have been hospitalized for heart failure in the prior year, and thus are eligible for CardioMEMS implantation. The CardioMEMS transiently requires a 12 Fr sheath for implantation, while the typical coronary sinus guides are 9 Fr. Compared with percutaneous access, control of venous bleeding may be more readily obtained in a device pocket where a figure-of-eight suture can be tightened around a sheath. While maneuvering the CardioMEMS delivery catheter around the right atrium, right ventricle, and pulmonary artery from the subclavian approach was more difficult than the typical femoral approach, it was easily managed without additional equipment. An additional theoretical risk is that prolongation of the time when the device pocket is open to air may increase the chance of infection; however, in this case, both devices were successfully implanted within 2 hours.

Advantages of simultaneous transradial angiography and device implantation include efficiency and patient convenience, while also providing real-time anatomical information (such as the levophase venogram), which reduces contrast utilization. However, the ability to anticoagulate the patient is limited, potentially the risk of radial artery occlusion. We have noted that with rapid deflation of the TR BAND over 60 minutes, attention to patent hemostasis, and use of the smallest appropriate sheath, radial occlusion is rare. While normally PCI is performed before device implantation, in this case, there was little indication that PCI would significantly increase the patient’s cardiac function. Staging of PCI allowed for preloading of P2Y12 inhibitors and aspirin, avoidance of a larger contrast dye load, and proceeding with devices that the patient would need in any case. 

Same-day discharge after cardiac implantable electronic device placement is increasingly utilized to increase efficiency, similar to same-day discharge after PCI.^5,6 Multiple randomized and observational studies have demonstrated the safety of this approach. As a routine, we will observe patients for 3-6 hours and obtain a chest x-ray and electrocardiogram, with an optional screen for pericardial effusions/accidental perforation using bedside echocardiography. 

Disclosures: Dr. Soe, Ms. Skendarian, and Dr. Rochon-Duck have no conflicts of interest to report regarding the content herein. Dr. Seto reports personal fees from Terumo Medical Corporation. 

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