Complete Four-Chamber Resynchronization:

A Novel Percutaneous Epicardial Pacing Lead

Martin van Zyl, MB BChCardiology Fellow

Mayo Clinic, Rochester, MN

Twitter: @DrMvanZyl

Email: vanZyl.Martin@Mayo.edu

Acknowledgements

Principal Investigator:

• Samuel Asirvatham

Co- Principal Investigator:

• Paul Friedman

Co-Investigators:

• Vaibhav Vaidya

• Alan Sugrue

• Omar Yasin

• Adetola Ladejobi

• Ammar Killu

• Jason Tri

Prototype Design:

• Joseph Duerr

Veterinary Technicians:

• Renee Taubel

• Lisa Yngsdal

• Joanne Pederson

Disclosures: Dr. Asirvatham has received honoraria for speaking from AtriCure, Biotronik,

Boston Scientific, Medtronic, Abbott, Zoll, and Johnson & Johnson.

Clinical Problem

Transvenous approach for pacemaker implantation:

• Unfavorable or obstructed venous anatomy

• Tricuspid valve regurgitation

• Bloodstream and device infection

• Extraction complications

• Stroke/TIA

Current Climate

• Global trend towards extravascular and small footprint devices

• Biventricular pacing → well established

• Biatrial pacing → some proposed benefits

Paroxysmal Atrial Fibrillation

Interatrial conduction delay

BEFORE AFTER

Ideal Solution

• 4 chamber “physiologic” pacing

• Minimally invasive percutaneous procedure

• Avoid transvenous approach

• Minimal exogenous material implanted

Hypothesis

Pacing Device

Four-Chamber

Pacing

Percutaneous

Epicardial

Implantation

Transverse

Pericardial

Sinus

Transverse Pericardial Sinus Anatomy

Experiment Plan

• Development of novel prototype device

• 12 acute canine experiments

1 2 3 4 5 6 7 8

Advancing the Lead

Final Position with Generator

12

34

56

78

AO

PA

Electrograms

RV

RA

LA

LV

Pacing/Sensing Parameters

0

1

2

3

4

Atrial(n=17)

Ventricular(n=27)

mA

@ 0

.5 m

s

Threshold

0

2

4

6

8

P Wave(n=15)

R Wave(n=25)

mV

Amplitude

0

200

400

600

800

Overall(n=20)

Ω

Impedance

Biventricular Pacing

Biventricular pacing could be achieved in 10 (83%)

Biatrial Pacing

Biatrial pacing could be achieved in 6 (50%)

Phrenic capture

• Mitigated by repositioning the device in all 5 (42%)

animals where this was noted

Subxyphoid Access Generator Pocket

Acute Complications

No acute complications were noted

Conclusion

In acute canine experiments, a novel transverse

sinus epicardial pacing device yielded:

• Safety and feasibility

• Reasonable pacing/capture parameters

• Biventricular and biatrial capture in majority

Limitations and Unknowns

• Long-term safety and efficacy

• Effect on hemodynamics, synchrony

• Chronic pericardial reaction

• Extraction feasibility

LAARAA

PA

AO

RVLV

Anterior

Posterior

LR

1*2*

34 5 6

78*

Questions? vanZyl.Martin

@Mayo.edu