A Hybrid Procedure Combining Mini-Thoracotomy with Interventional Endocardial Lead Implantation for Cardiac Resynchronization Therapy in Patients with Chronic Congestive Heart Failure: A Report of Four Cases
Keywords:epicardial lead; hybrid procedure; mini-thoracotomy; cardiac resynchronization therapy; congestive heart failure; implantation
Background: We describe the application and effectiveness of transthoracic electrode implantation for epicardial left ventricular pacing in cardiac resynchronization therapy (CRT) for patients with chronic congestive heart failure.
Methods: We assessed four patients with chronic congestive heart failure for whom implantation of endocardial electrodes was contraindicated. The epicardial electrodes were implanted via a mini-thoracotomy in the fourth or fifth left intercostal space. We analyzed the surgical implantation technique and the short-term effectiveness of the procedure.
Results: The epicardial electrodes successfully were implanted in all four patients. The patients’ hemodynamic status, cardiac function, and symptoms significantly improved. Patients I, II, III, and IV were discharged from the hospital on the 8, 11, 4, and 7 days, respectively, after the operation. Follow up lasted for 12 months. None of the patients presented with electrode fractures or surgical wound infections, and the pacing threshold and electrode impedance were normal. In one case, phrenic nerve stimulation occurred due to the low placement position of the electrode. When the electrode was moved slightly inward and upward, the sacral nerve stimulation sign disappeared, and no other complications were noted. One patient developed capsule infection, and the presence of an ectopic pacemaker was noted; therefore, a pacemaker replacement procedure was required.
Conclusion: In CRT, the implantation of a left ventricular epicardial electrode through a left-sided small incision is safe, feasible, and effective. This hybrid surgery combining interventional and cardiac techniques can maximize the curative effect of CRT.
Bhaskaran A, Tung R, Stevenson WG, et al. 2019. Catheter Ablation of VT in Non-Ischaemic Cardiomyopathies: Endocardial, Epicardial and Intramural Approaches [J]. Heart Lung Circ 28(1):84-101.
Biffi M, Boriani G. 2011. Phrenic stimulation management in CRT patients: are we there yet? [J]. Curr Opin Cardiol 26(1):12-16.
Brennan EJ. 2018. Chronic heart failure nursing: integrated multidisciplinary care [J]. Br J Nurs 27(12):681-688.
Champagne J, Healey JS, Krahn AD, et al. 2011. The effect of electronic repositioning on left ventricular pacing and phrenic nerve stimulation [J]. Europace 13(3):409-415.
Drugs for chronic heart failure [J]. 2019. Med Lett Drugs Ther 61(1569):49-54.
Edgerton JR, Edgerton ZJ, Mack MJ, et al. 2007. Ventricular epicardial lead placement for resynchronization by determination of paced depolarization intervals: technique and rationale [J]. Ann Thorac Surg 83(1):89-92, 92.
Gurevitz O, Nof E, Carasso S, et al. 2005. Programmable multiple pacing configurations help to overcome high left ventricular pacing thresholds and avoid phrenic nerve stimulation [J]. Pacing Clin Electrophysiol 28(12):1255-1259.
Harjola VP, Parissis J, Brunner-La R H, et al. 2018. Comprehensive in-hospital monitoring in acute heart failure: applications for clinical practice and future directions for research. A statement from the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) [J]. Eur J Heart Fail 20(7):1081-1099.
Hoosain J, Whittier J, Hasni F, et al. 2017. The Initial Evaluation and Management of a Patient with Heart Failure [J]. Curr Cardiol Rep 19(10):103.
Huntley GD, Deshmukh AJ, Warnes CA, et al. 2018. Longitudinal Outcomes of Epicardial and Endocardial Pacemaker Leads in the Adult Fontan Patient [J]. Pediatr Cardiol 39(7):1476-1483.
Konstantinides SV, Meyer G, Becattini C, et al. 2020. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) [J]. Eur Heart J 41(4):543-603.
Marini M, Branzoli S, Moggio P, et al. 2020. Epicardial left ventricular lead implantation in cardiac resynchronization therapy patients via a video-assisted thoracoscopic technique: Long-term outcome [J]. Clin Cardiol 43(3):284-290.
Nelson KE, Bates MG, Turley AJ, et al. 2013. Video-assisted thoracoscopic left ventricular pacing in patients with and without previous sternotomy [J]. Ann Thorac Surg 95(3):907-913.
Ohlow MA, Lauer B, Brunelli M, et al. 2013. The Use of a Quadripolar Left Ventricular Lead Increases Successful Implantation Rates in Patients with Phrenic Nerve Stimulation and/or High Pacing Thresholds Undergoing Cardiac Resynchronisation Therapy with Conventional Bipolar Leads [J]. Indian Pacing Electrophysiol J 13(2):58-65.
Perrin T, Maille B, Lemoine C, et al. 2018. Comparison of epicardial vs. endocardial reimplantation in pacemaker-dependent patients with device infection [J]. Europace 20(4):e42-e50.
Separham A, Pourafkari L, Kazemi B, et al. 2019. Vitamin D deficiency and functional response to CRT in heart failure patients [J]. Herz 44(2):147-154.
Varma N, Boehmer J, Bhargava K, et al. 2019. Evaluation, Management, and Outcomes of Patients Poorly Responsive to Cardiac Resynchronization Device Therapy [J]. J Am Coll Cardiol 74(21):2588-2603.
Vereckei A, Szelenyi Z, Kutyifa V, et al. 2018. Novel electrocardiographic dyssynchrony criteria improve patient selection for cardiac resynchronization therapy [J]. Europace 20(1):97-103.