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Ann Thorac Surg 2004;77:1472-1474
© 2004 The Society of Thoracic Surgeons

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How to do it

Robotically assisted left ventricular epicardial lead implantation for biventricular pacing: the posterior approach

^a Division of Cardiothoracic Surgery, St. Luke's-Roosevelt Hospital Center and Columbia University College of Physicians and Surgeons, New York, New York, USA

Accepted for publication April 9, 2003.

^* Address reprint requests to Dr DeRose, 1090 Amsterdam Ave, Suite 7A, New York, NY, USA 10025
e-mail: jjd11{at}columbia.edu

	Abstract

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Patients with congestive heart failure and altered interventricular conduction enjoy improvements in quality of life and ventricular function after successful resynchronization therapy with biventricular pacing. Technical limitations owing to individual coronary sinus and coronary venous anatomy result in a 10% to 15% failure rate of left ventricular (LV) lead placement through percutaneous approaches. To provide a minimally invasive option for these patients with LV lead failures, we developed a technique of endoscopic, epicardial LV lead implantation with the use of the da Vinci robotic system. The surgical approach targets the posterolateral wall through a novel posterior approach.

	Introduction

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Prospective randomized trials have demonstrated improvements in ventricular function, exercise capacity, and quality of life among patients undergoing ventricular resynchronization therapy with biventricular pacing [1–4]. However, technical limitations owing to individual coronary sinus and coronary venous anatomy result in a 10% to 15% failure rate of left ventricular (LV) lead placement and effective biventricular pacing [3, 4]. Lead dislodgement contributes to an additional 5% to 10% late failure rate of left ventricular lead capture [5]. Rescue therapy for these frail patients has typically involved left ventricular epicardial lead placement through a limited anterior thoracotomy.

To provide a minimally invasive option for these patients with LV lead failures, we began a program of endoscopic, epicardial LV lead placement with the use of the da Vinci robotic system (Intuitive Surgical Inc, Sunnyvale, CA). We describe a novel technique of posterior access to the LV surface aimed at targeting the most advantageous region of the left ventricle for effective resynchronization.

	Technique

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The da Vinci robotic surgical system is used for all portions of the operation. The device is composed of the surgeon control console and the surgical arm unit that positions and directs the micro-instruments. Computer interfacing allows for scaled motion, and the optics viewed in the surgeon console allow for high-definition, magnified, real three-dimensional vision.

All operations are performed under general anesthesia with selective right lung ventilation. Transesophageal echocardiography is performed routinely. The patient is placed in the full posterolateral thoracotomy position and a camera port is placed in the seventh intercostal space (ICS) in the posterior axillary line. The left and right arms are positioned in the ninth and fifth ICS, respectively (Fig 1). The left chest is insufflated at a pressure of 8 to 10 mm Hg. A 10-mm working port is inserted posterior to the camera port and is used for the introduction of the lead and sutures as necessary. The pericardium is then opened posterior to the phrenic nerve, and the first and second obtuse marginal vessels are identified (Fig 2). The pericardium is then retracted posteriorly with sutures that are brought out of the working port.

View larger version (37K): [in this window] [in a new window]   Fig 1. Port placement for totally endoscopic, robotic left ventricular epicardial lead implantation. The ports are placed in line with the tip of the scapula allowing for posterior access to the left ventricular surface.

View larger version (122K): [in this window] [in a new window]   Fig 2. Operative photograph of robotic left ventricular lead placement. The pericardium is divided posterior to the phrenic nerve exposing the obtuse marginal vessels on the posterolateral wall of the left ventricle. A two-turn, helical screw-in lead is being placed in between the first and second obtuse marginal vessels, midway between the apex and the base of the LV. (OM = obtuse marginal artery.)

The first lead is then retrieved from the chest through the right arm port. Both leads are then tunneled to a counter incision in the axilla. A chest tube is placed through the left arm port for evacuation of air and is removed before leaving the operating room. The port sites are closed and the patient is repositioned in the supine position. Both LV leads are retrieved into the pocket and retested for threshold. The LV lead with the best threshold is used as the pacing lead and is connected to the device. The second lead is secured to the fascia and is left capped in the pocket as a backup lead for future use if necessary. If a right-sided pacing or defibrillating lead is required, it is inserted at this time and the leads are connected to either a biventricular pacing generator or an ICD/biventricular pacing device.

We have performed this procedure on 13 patients to date. Six patients (46%) have had prior coronary artery bypass grafting (CABG). Improvements in exercise tolerance (11 of 13 patients), ejection fraction (12% ± 6% vs 19% ± 13%, p = 0.04), and QRS duration (184 ± 31 vs 152 ± 21 milliseconds, p < 0.01) have been noted at 3- to 6-month follow-up. Lead thresholds have remained unchanged, and a significant drop in impedance has been measured in 6-month follow-up.

	Comment

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The success of ventricular resynchronization therapy relies heavily upon proper LV lead placement. Previous studies have demonstrated that pacing the posterolateral wall of the LV provides more effective hemodynamic augmentation than either lateral or anterior positioned leads [6, 7]. Despite successful coronary sinus cannulation in 85% of percutaneous LV lead insertions, a much smaller percentage of these patients actually receive leads positioned in the posterolateral vertical vein of the coronary sinus. Long operative and fluoroscopy times have likewise made percutaneous coronary sinus LV lead placement a challenging and meticulous procedure.

Direct access to the LV surface has been described previously as a rescue procedure in patients with failed coronary sinus leads. These procedures have included both limited thoracotomy and thoracoscopic techniques. All of these procedures, however, have targeted the anterior and lateral LV wall for LV lead placement and have included limited access to the entire LV surface. The presently described posterior approach has several advantages. Access to the most posterior portion of the LV is possible as far back as the distal circumflex. Likewise, more lateral and anterolateral regions of the LV can be easily targeted should preoperative studies or intraoperative mapping suggest a more beneficial lead site. Posterior lead placement has proven most effective in all cases to date, regardless of the etiology of the cardiomyopathy. Likewise, the posterior surface in the region of OM1 and OM2 invariably is an area of the LV with a bare myocardial surface, devoid of epicardial fat, allowing for excellent lead thresholds.

The posterior approach is critical for reoperative surgery. In patients with prior CABG, exposure to the posterior pericardium can be facilitated by the mobilization of preexisting lung adhesions. Because the posterior pericardial well is frequently the least involved in the adhesive process, the posterior approach typically allows for direct entry into the pericardial space. The intrapericardial adhesions can be easily dissected with electrocautery and posterior grafts are easily identified.

Although the majority of patients referred for robotic LV lead implantation have had a prior failure of coronary sinus cannulation, the procedure may have potential benefits as a primary implantation. Access to the entire heart gives the surgeon the ability to place the LV lead in the most hemodynamic and electrophysiologic advantageous position based on both preoperative and intraoperative studies. The reproducibility of the procedure allows it to be done with a near 100% immediate success rate in a very expeditious manner. A larger randomized study will be necessary in order to determine if robotic LV epicardial lead implantation results in improved functional outcome when compared with coronary sinus LV lead placement.

	References

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1. Cazeau S., LeClerq C., Lavergne T., et al. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med 2001;344:873-880.[Abstract/Free Full Text]
2. Reuter S., Garigue S., Bordachar P., et al. Intermediate-term results of biventricular pacing in heart failure: correlation between clinical and hemodynamic data. PACE 2000;23:1713-1717.
3. Gras D., Mabo P., Tang T., et al. Multisite pacing as a supplemental treatment of congestive heart failure: preliminary results of the Medtronic InSync study. PACE 1998;21:2249-2255.
4. Abraham W.T., Fischer W.G., Smith A.L., et al. Cardiac resynchronization in chronic heart failure. N Engl J Med 2002;346:1845-1853.[Abstract/Free Full Text]
5. Alonso C., Leclercq C., d'Allones F.R., et al. Six year experience of transvenous left ventricular lead implantation for permanent biventricular pacing in patients with advanced heart failure: technical aspects. Heart (British Cardiac Society) 2001;86:405-410.
6. Butter C., Auricchio A., Stellbrink C., et al. Effect of resynchronization therapy stimulation site on the systolic function of heart failure patients. Circulation 2001;104:3026-3029.[Abstract/Free Full Text]
7. Ansalone G., Giannantoni P., Ricci R., Trambaiolo P., Fedele F., Santini M. Doppler myocardial imaging to evaluate the effectiveness of pacing sites in patients receiving biventricular pacing. J Am Coll Cardiol 2002;39:489-499.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Daniel G. Swistel Robert C. Ashton, Jr Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Derose, J. J. Articles by Ashton, R. C. Search for Related Content PubMed PubMed Citation Articles by Derose, J. J., Jr Articles by Ashton, R. C., Jr Related Collections Electrophysiology - arrhythmias