A Novel Approach for Endocardial Resynchronization Therapy: Initial Experience with Transapical Implantation of the Left Ventricular Lead

  • Imre Kassai
  • Attila Mihalcz
  • Csaba Foldesi
  • Attila Kardos
  • Tamas Szili-Torok

Abstract

Background: Coronary sinus lead placement for transvenous left ventricular (LV) pacing in cardiac resynchronization therapy (CRT) has a significant failure rate at implant and a considerable dislocation rate during follow-up. For these patients epicardial pacing lead implantation is the most frequently used alternative. Recent data support endocardial lead implantation through the atrial septum and the mitral valve, because this method provides further hemodynamic advantages. On the other hand transseptal CRT carries a significant risk for device related infective endocarditis of the mitral valve. The aim of this prospective, nonrandomized study was to demonstrate the feasibility of a fundamentally new approach for endocardial LV lead implantation.

Methods: We performed 12 transapical LV lead implantations in 10 end-stage heart failure patients. In each operation an active fixation lead was placed into the LV cavity using standard Seldinger technique through the LV apex. By use of a J-shaped guide wire, the tip of the lead was positioned and fixed into the basal-lateral segment of the LV under fluoroscopy guidance. Pacing parameters were assessed and found to be optimal in all patients. The lead was conducted through the chest wall near the apex into a subcutaneous tunnel up to the pocket of the previously implanted device. After surgery the patients are anticoagulated with target anticoagulation level identical to mechanical valve prostheses.

Results: In 8 patients there were no major or minor complications related to this new technique. During the follow-up period (mean 7.2 ± 4.1 months) all patients responded favorably to the treatment. One lead dislocation and 1 pocket infection were detected; the lead repositioning and replacing could be performed without reopening of the pleural cavity.

Conclusions: The potential advantages of this new technique are that it is minimally invasive, endocardial, and does not involve the mitral valve. LV lead repositioning can also be performed minimally invasively.

References

Abraham WT, Fisher WG, Smith AL, et al. 2002. MIRACLE Study Group. Multicenter insync randomized clinical evaluation: cardiac resynchronization in chronic heart failure. N Engl J Med 346:1845-53.\nGarrigue S, Jais P, Espil G, et al. 2001. Comparison of chronic biventricular pacing between epicardial and endocardial left ventricular stimulation using Doppler tissue imaging in patients with heart failure. Am J Cardiol 88:858-62.\nGelder BM, Scheffer MG, Meijer A, Bracke FA 2007. Transseptal endocardial left ventricular pacing: an alternative technique for coronary sinus lead placement in cardiac resynchronization therapy. Heart Rhythm 4:454-60.\nKassai I, Földesi C, Székely A, Szili-Török T 2009. Alternative method for cardiac resynchronization: transapical lead implantation. Ann Thorac Surg 87:650-2.\nKassai I, Szili-Torok T 2008. Concerns about the long-term outcome of transseptal cardiac resynchronization therapy: What we have learned from surgical experience. Europace 10:121-2.\nYpenburg C, van Bommel RJ, Borleffs CJW, et al. 2009. Long-term prognosis after cardiac resynchronization therapy is related to the extent of left ventricular reverse remodeling at midterm follow-up. J Am Coll Cardiol 53:483-90.\n
Published
2009-06-22
Section
Articles