Predictors of fluoroscopy time and procedural failure during biventricular device implantation

Biventricular device implantation with the insertion of a transvenous left ventricular (LV) lead can be challenging. The aim of this study was to identify predictors of procedural difficulty measured by fluoroscopy time and predictors of LV lead implantation failure. A single-center, retrospective study of 272 consecutive patients who underwent biventricular device implantation from 2004 to 2011 was conducted. Multivariate linear regression was used to assess predictors of fluoroscopy time and logistic regression to identify predictors of LV lead implant failure. The median fluoroscopy time was 36.1 minutes (interquartile range 24.2 to 51.6). After multivariate adjustment, independent predictors of longer fluoroscopy time included a right-sided approach (21.8 minutes longer, 95% confidence interval [CI] 6.8 to 36.9, p = 0.005), previous congenital heart disease surgery (64.6 minutes longer, 95% CI 30.2 to 99.0, p <0.001), and previous failed attempt (30.3 minutes longer, 95% CI 6.0 to 54.5, p = 0.015). Predictors of shorter fluoroscopy time included an LV lead upgrade (7.5 minutes shorter, 95% CI 0.6 to 14.4, p = 0.033), electrophysiology fellow experience (5.4 minutes shorter/year, 95% CI 0.1 to 10.7, p = 0.047), and attending physician experience (1.4 minutes shorter/year, 95% CI 0.01 to 2.9, p = 0.049). Failed implantation occurred in 8% of patients (22 of 272); inability to cannulate the coronary sinus and absent or atretic coronary sinus veins were the most common reasons (8 of 22 failed implants each). A previous failed attempt was the only significant predictor of LV lead implantation failure (odds ratio 33.5, 95% CI 3.2 to 352.6, p = 0.003). In conclusion, 6 patient and operator characteristics predicted LV lead implantation difficulty measured by fluoroscopy time. LV lead implantation failed in 8% of cases, predicted only by a previous failed attempt.