1. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Previously Failed CRT Cases Implanted Successfully Using a Guide Support Based Telescoping CRT Delivery System Seth J. Worley MD FHRS FACC Implant Program The Heart Center Lancaster General Hospital Lancaster, PA. USA

2. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Conflict of Interest: The two cases presented here had failed implant attempts by experienced implanters at other centers.The two cases presented here had failed implant attempts by experienced implanters at other centers. A variety of device company delivery systems were used in both failed.A variety of device company delivery systems were used in both failed. The author developed and has intellectual property rights for the telescoping guide based delivery system used for the successful implants described hereThe author developed and has intellectual property rights for the telescoping guide based delivery system used for the successful implants described here

3. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Ergonomics for LV Lead Implantation When implanting LV leads turning the table to the position illustrated in Panel B improves the ergonomicsWhen implanting LV leads turning the table to the position illustrated in Panel B improves the ergonomics The assistant is in a better position to helpThe assistant is in a better position to help The catheters are not kinkedThe catheters are not kinked

4. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 CRT-indicated 75 year old male was referred to our center following a failed 3 hour attempt using various device company delivery systems.CRT-indicated 75 year old male was referred to our center following a failed 3 hour attempt using various device company delivery systems. The attempt at the other center failed because the LV lead would not track over the wire into the target vein despite the use of multiple types of wires.The attempt at the other center failed because the LV lead would not track over the wire into the target vein despite the use of multiple types of wires.

5. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 At our center initial coronary sinus (CS) access was obtained with the 9F Pressure Products SafeSheathCSG® Braided Core Worley- STD® anatomically- shaped, peel-away sheath (sheath).At our center initial coronary sinus (CS) access was obtained with the 9F Pressure Products SafeSheathCSG® Braided Core Worley- STD® anatomically- shaped, peel-away sheath (sheath).

6. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 Occlusive CS venography was performedOcclusive CS venography was performed The target vein attempted at the other institution was identified in the AP projection.The target vein attempted at the other institution was identified in the AP projection.

7. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 The target vein attempted at the other institution was identified in the LAO projection.The target vein attempted at the other institution was identified in the LAO projection.

8. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 The 5 F vein selector was inserted into the a 9 F SafeSheath® Worley Telescopic Braided Series Renal Lateral Vein Introducer® from Pressure Products (9 F “Renal” LVI guide).The 5 F vein selector was inserted into the a 9 F SafeSheath® Worley Telescopic Braided Series Renal Lateral Vein Introducer® from Pressure Products (9 F “Renal” LVI guide).

9. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 The vein selector/LVI guide were inserted into the long 9 F sheath located in the CS.The vein selector/LVI guide were inserted into the long 9 F sheath located in the CS.

10. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 The “Renal” LVI guide was advanced to the tip of the the long 9 F sheath located in the CS.The “Renal” LVI guide was advanced to the tip of the the long 9 F sheath located in the CS. The vein selector was advanced into the CS.The vein selector was advanced into the CS. The target vein was identified with puffs of contrast from the vein selectorThe target vein was identified with puffs of contrast from the vein selector

11. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 The vein selector was advanced into the target vein.The vein selector was advanced into the target vein. An angioplasty wire was then advanced into the vein through the vein selector.An angioplasty wire was then advanced into the vein through the vein selector. The vein selector was advanced further into the vein over the wire.The vein selector was advanced further into the vein over the wire.

12. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 Using the angioplasty wire and a vein selector as a rail the “Renal LVI guide was advanced into the vein.Using the angioplasty wire and a vein selector as a rail the “Renal LVI guide was advanced into the vein.

13. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 The vein selector was removed.The vein selector was removed. Contrast injection confirmed that the tip of the Renal LVI guide was in the veinContrast injection confirmed that the tip of the Renal LVI guide was in the vein

14. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 The 6 F pacing lead was then easily advanced into the vein.The 6 F pacing lead was then easily advanced into the vein. The “Renal” LVI guide was cut awayThe “Renal” LVI guide was cut away The sheath was pealed awayThe sheath was pealed away

15. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 1 The implant time from incision to lead tie down was 25 minutes.The implant time from incision to lead tie down was 25 minutes.

16. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 2 CRT-indicated 53 year old female was referred to our center following a failed 2 1/2 hour attempt using the device company delivery system.CRT-indicated 53 year old female was referred to our center following a failed 2 1/2 hour attempt using the device company delivery system. The attempt at the other center failed because the LV lead would not track over the wire into the target vein despite the use of multiple types of wires.The attempt at the other center failed because the LV lead would not track over the wire into the target vein despite the use of multiple types of wires.

17. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 2 At our center initial coronary sinus access was obtained with the 9 F Pressure Products SafeSheathCSG® Braided Core Worley-STD® anatomically-shaped, peel- away sheath.At our center initial coronary sinus access was obtained with the 9 F Pressure Products SafeSheathCSG® Braided Core Worley-STD® anatomically-shaped, peel- away sheath.

18. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 2 The occlusive CS venogram demonstrated the target vein attempted at the other centerThe occlusive CS venogram demonstrated the target vein attempted at the other center

19. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 2 Using the approach described in Case 1 a SafeSheath® Worley 9F Telescopic Braided Series Renal Lateral Vein Introducer® (“Renal” LVI guide) was advanced into the target veinUsing the approach described in Case 1 a SafeSheath® Worley 9F Telescopic Braided Series Renal Lateral Vein Introducer® (“Renal” LVI guide) was advanced into the target vein

20. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Case 2 A 6 F bipolar lead was then advanced into the target vein.A 6 F bipolar lead was then advanced into the target vein. The guide was cut away.The guide was cut away. The sheath pealed away.The sheath pealed away. Implant time was 20 minutes from incision to LV lead tie downImplant time was 20 minutes from incision to LV lead tie down

21. . March 1st to 15th, 2009.ISHNE CRT World-Wide Internet Symposium 2009 Seth J. Worley MD Conclusion Inability to advance the LV lead despite successfully placing a wire in the target vein prevents successful implantation in some cases.Inability to advance the LV lead despite successfully placing a wire in the target vein prevents successful implantation in some cases. Delivery systems are available that provide the guide support necessary for successful implantation.Delivery systems are available that provide the guide support necessary for successful implantation.