The Jurdham Procedure for Endocardial Cardiac Resynchronization Therapy: Long Term Follow-Up in 19 Patients

Aim: Endocardial left ventricular (LV) pacing for cardiac resynchronization therapy (CRT) presents clear advantages over coronary sinus (CS) lead implantation. At present, simple and safe procedures for implantation have been developed. However, data regarding long term clinical results and actual complications are needed in order to overcome early concerns. We present our long term follow up (FU) of pts who underwent endocardial CRT using the Jurdham procedure.

Methods and Results: Since August 2009 to September 2015, 50 patients (pts) underwent the Jurdham procedure, of which 19 reached at least 18 months (m) follow up (FU). The Jurdham procedure was performed in pts willing and able to take optimal vitamin K antagonist therapy (INR of 2-3) or Novel Oral Anticoagulants (NOACs) and with an accepted indication for CRT. Early in our experience this procedure was performed only in pts with a previous failed CRT implant, unsuitable coronary sinus anatomy or sub-optimal response. As of January 2014 we offered this procedure as a first option to previously anticoagulated patients undergoing their initial device implant.19 pts, (62.37± 9.27 y.o.,15 males, LVEF 21.84± 5.10%, QRS 172.63 ± 8.88 ms, NYHA Class (FC) 2.95 ± 0.52 ischemic-necrotic 6, idiopatic 10, Chagas disease 2, non compacted miocardiopathy 1 were implanted and followed for 40.14± 12.31 months (m), (range 18 - 72 m). LV leads were implanted in the lateral or posterolateral medial LV region in all pts. No surgical, thromboembolic or complications occurred during the FU period. All patients maintained adequate average levels of INR with a target INR of 2 -3. Acute LV threshold was 0.64 ± 0.27 V and 0.62 ± 0.24, 0.64 ± 0.11, 0.57± 0.15 and 0.60 ± 0.19V at 6, 12 and 18 m respectively. NYHA FC at 6, 12 and 18 m was 1.32 ± 0.48, 1.40 ± 0.51 and 1.36 ± 0.50 respectively. EF at 6,12, and 18 months was 30.36 ± 4.68%, 33.87 ± 7.97% and 33.00 ± 7.44%. No new or increased mitral regurgitation was observed. Six patients died: 3 from progressive CHF (at 8,11, and16 m) one with incessant ventricular tachycardia (8 m), one from septicemia after 2 previous failed CS attempts(4m) and one patient with septic shock due to pneumonia (8m).

Conclusions: In our experience, endocardial CRT using the Jurdham procedure was effective and safe, with satisfactory clinical results at a long term FU and no significant mitral regurgitation, LV lead related infections or thrombo-embolic complications in adequately anticoagulated pts. If longer FU studies confirm these results, endocardial CRT might become widespread used.