Epicardial lead implantation techniques for biventricular pacing via left lateral mini-thoracotomy, video-assisted thoracoscopy, and robotic approach.

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.