Epicardial Lead Implantation Techniques for Biventricular Pacing via Left Lateral Mini-Thoracotomy, Video-Assisted Thoracoscopy, and Robotic Approach
DOI:
https://doi.org/10.1532/hsf.663Abstract
Purpose: For optimal biventricular pacing, the left ventricular (LV) lead has been found to be best placed in the area where optimal concordance is achieved between the LV pacing site and the site of the most delayed LV wall. For anatomical or technical reasons, the placement of the LV lead via the coronary sinus at the intended target area of the LV is often not possible. An option for avoiding these drawbacks is the surgical implantation of the LV lead under direct vision. This report describes 3 epicardial lead implantation techniques that are less invasive.
Methods: In 80 patients with advanced heart failure and left bundle branch block, epicardial LV leads for biventricular pacing were implanted with 3 different methods: (1) left lateral mini-thoracotomy; (2) a video-assisted thoracoscopy approach using lead implantation tools; and (3) a robotically enhanced telemanipulation system. Video films are provided for all 3 techniques in The Heart Surgery Forum online.
Results: Independent of the surgical techniques, the intended lead location on the LV was achieved in all patients. Acute and 3-month LV lead thresholds were satisfactory in 79 patients (99%). Two lead displacements were observed. One thoracotomy was carried out after thoracoscopic lead placement because the patient developed an early exit block. Five patients who underwent an operation with the robot needed a conversion to thoracotomy because of technical failure of the robot (2 patients) or massive pleural adhesions (3 patients). There were no severe adverse events related to any technique. Three patients died in the hospital from the progression of end-stage heart failure.
Conclusion: Epicardial lead implantation for biventricular pacing is feasible with all 3 surgical techniques. Each method allows optimal lead implantation under direct vision and therefore reduces the incidence of nonresponders resulting from suboptimal lead placement.
References
Abraham WT, Fisher WG, Smith AL, et al, and the MIRACLE Study Group. Multicenter InSync Randomized Clinical Evaluation. 2002.nCardiac resynchronization in chronic heart failure. N Engl J Med 346:1845-53.nAnsalone G, Giannantoni P, Ricci R, et al. 2001. Doppler myocardial imaging in patients with heart failure receiving biventricular pacing treatment. Am Heart J 142:881-96.nAnsalone G, Giannantoni P, Ricci R, Trambaiolo P, Fedele F, Santini M. 2003. Biventricular pacing in heart failure: back to basics in the pathophysiology of left bundle branch block to reduce the number of nonresponders. Am J Cardiol 91:55F-61F.nPurerfellner H, Nesser HJ, Winter S, Schwierz T, Hornell H, Maertens S. 2000. Transvenous left ventricular lead implantation with the EASY-TRAK lead system: the European experience. Am J Cardiol 86(suppl 1): K157-64.nSachweh JS, Vazquez-Jimenez JF, Schondube FA, et al. 2000. Twenty years experience with pediatric pacing: epicardial and transvenous stimulation. Eur J Cardiothorac Surg 17:455-61.nSalukhe TV, Francis DP, Sutton R. 2003. Comparison of medical therapy, pacing and defibrillation in heart failure (COMPANION) trial terminated early: combined biventricular pacemaker-defibrillators reduce all-cause mortality and hospitalization. Int J Cardiol 87:119-20.nYoung JB, Abraham WT, Smith AL, et al, and the Multicenter InSync ICD Randomized Clinical Evaluation (MIRACLE ICD) Trial Investigators. 2003. Combined cardiac resynchronization and implantable cardio-version defibrillation in advanced chronic heart failure: the MIRACLE ICD trial. JAMA 289:2685-94.nAuricchio A, Ding J, Spinelli JC, et al. 2002. Cardiac resynchronization therapy restores optimal atrioventricular mechanical timing in heart failure patients with ventricular conduction delay. J Am Coll Cardiol 39:1163-9.nBeaufort-Krol GC, Mulder H, Nagelkerke D, Waterbolk TW, Bink-Boelkens MT. 1999. Comparison of longevity, pacing, and sensing characteristics of steroid-eluting epicardial versus conventional endocardial pacing leads in children. J Thorac Cardiovasc Surg 117:523-8.nBristow MR, Feldman AM, Saxon LA. 2000. Heart failure management using implantable devices for ventricular resynchronization: Comparison of Medical Therapy, Pacing, and Defibrillation in Chronic Heart Failure (COMPANION) trial: COMPANION Steering Committee and COMPANION Clinical Investigators. J Card Fail 6:276-85.nCazeau S, Leclercq C, Lavergne T, et al, and the Multisite Stimulation in Cardiomyopathies (MUSTIC) Study Investigators. 2001. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med 344:873-80.nDaoud EG, Kalbfleisch SJ, Hummel JD, et al. 2002. Implantation techniques and chronic lead parameters of biventricular pacing dual-chamber defibrillators. J Cardiovasc Electrophysiol 13:964-70.nFatemi M, Etienne Y, Gilard M, Mansourati J, Blanc JJ. 2003. Short and long-term single-centre experience with an S-shaped unipolar lead for left ventricular pacing. Europace 5:207-11.nJansens JL, Wellens F, Ducart A, Stoupel E, Canniere DD. 2003. Robotic enhanced epicardial lead implantation for biventricular resynchronization therapy. Heart Surg Forum 6(suppl 1):S25.nMedtronic. 2003. Epicardial lead implant tool information page. Medtronic, Inc. Web site. Available at: http://www.medtronic.com/cardsurgery/ products/epi_lead.html. Accessed August 21, 2003.n
