Ann Thorac Surg 2005;80:751-754
© 2005 The Society of Thoracic Surgeons
How to do it
Minimally Invasive Surgical Alternatives for Left Ventricle Epicardial Lead Implantation in Heart Failure Patients
José L. Navia, MD
*
,
Fernando A. Atik, MD
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
Accepted for publication March 8, 2004.
* Address reprint requests to Dr Navia, Department of Thoracic and Cardiovascular Surgery, F-25, Cleveland Clinic Foundation, 19500 Euclid Ave, Cleveland, OH44195; (Email: naviaj{at}ccf.org).
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Abstract
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Biventricular pacing is a proven advantageous adjuvant therapy for patients with ventricular dyssynchrony associated with congestive heart failure. Endocardial left ventricular lead placement does have several limitations: anatomic variations of the coronary venous system and late lead dislodgement. Epicardial lead placement is often a rescue procedure but offers some advantages related to safety and a shorter implant time. Moreover, it allows visual selection of the best pacing site and multiplicity of pacing sites. Three minimally invasive surgical methods of left ventricular lead placement are outlined in this article, including specific indications and limitations. Biventricular pacing has been proposed as an adjuvant treatment for patients with heart failure and intraventricular conduction delay.
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Introduction
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Patient selection for biventricular pacing included those with advanced heart failure in New York Heart Association functional class III or IV and with a QRS duration of more than 130 ms. Usually, patients had previously undergone transvenous endocardial lead placement in the right atrium and right ventricle and had failed implantation of the left ventricular lead through the coronary sinus.
Before operation, patients need to be assessed by a cardiac anesthesiologist for general anesthesia and single-lung ventilation. During operation, patients are routinely monitored with a 12-lead electrocardiogram and defibrillator pads attached to the skin. Hemodynamics are assessed with invasive arterial pressure, a pulmonary artery thermodilution catheter, and transesophageal echocardiography. Patients who have undergone previous open-heart operations must be assessed for feasibility of groin cannulation in an emergency. General anesthesia is performed with double-lumen endotracheal intubation. At this juncture, the safety of single-lung ventilation must be verified.
Indications for a specific surgical approach are according to the following general guidelines. Minithoracotomy is selected for 2 patient populations: those with severely enlarged left ventricles and those who have undergone previous cardiothoracic operations. In these patients, total thoracoscopic procedures would be difficult and potentially dangerous, because limited space restricts safe manipulation of the instruments, and they may inadvertently trigger life-threatening arrhythmias or hemodynamic compromise. Video-assisted thoracoscopic surgery (VATS) is indicated in patients with adequate anterior-posterior chest diameter; reoperations are not a contraindication, but minithoracotomy is preferred most of the time. Robotics is indicated in patients with a small cardiothoracic ratio and can be challenging in reoperations.
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Technique
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For minithoracotomy, a skin incision 3 to 5 cm long is made over the fourth or fifth left intercostal spaces just anterior to the midaxillary line. In a small incision, the use of a self-retaining retractor (Cloward; Aesculap, Center Valley, PA) is helpful because its deep blades allow adequate exposure (Fig 1). Single-lung ventilation is initiated; if adherent, the left lung is dissected free and retracted posteriorly. The pericardium is tented with forceps and carefully opened anteriorly to the phrenic nerve. Proceeding with extreme caution is advisable for patients who have had previous heart surgery, particularly coronary artery bypass grafting. Better exposure of the posterior lateral wall of the left ventricle can be obtained by placing stay sutures in the pericardium. Our service routinely uses 2 screw-in pacing leads (Medtronic model 5071 Pacing Lead; Minneapolis, MN), which must be turned clockwise twice to get appropriately fixed. Eluting sew-in leads certainly can be applied, but this is technically more demanding through minimally invasive approaches. If the left ventricular wall has a sufficient thickness, the helix of the lead can be pulled out 1 mm to facilitate easier implantation. Sometimes, the ventricular wall is not aligned with the incision, and this makes direct implantation difficult. In this case, it is helpful to use the epicardial lead implant tool (Medtronic model 10626) or a thoracoscopic grasper inserted in a more posterior small incision (Fig 2). This can be used as a draining site.
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Fig 1. Minithoracotomy for left ventricular epicardial lead implantation, showing the incision site (upper left), patient position (upper right), and good exposure of the heart with a self-retaining retractor and lung deflation.
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Fig 2. Implantation of epicardial leads through a minithoracotomy, showing the use of a thoracoscopic manipulation tool (left) to place the leads in the posterolateral wall of the left ventricle (right).
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After the leads have been placed and assessment is made with a pacing system analyzer for thresholds less than 1 V, the leads are brought out of the chest cavity to ensure sufficient slack to allow free lung movement. The leads are then tunneled to the pacemaker generator pocket. The lead with the lowest threshold is connected; the other lead is capped and left as a backup alternative. After adequate hemostasis is obtained, a size 10 Jackson-Pratt drain is placed into the left pleura. Before closing the incision by layers, it is important to test the device to ensure that no other adjustments are required.
For VATS, the patient is placed in a supine position with the left arm placed slightly below the table level. This maneuver prevents interference with tool manipulation during the procedure. Port position will depend on heart size and position. Usually, a fifth and sixth space anterior and midaxillary port for tools and a second or third space midanterior clavicular port for the scope are standard (Fig 3). Sometimes, an auxiliary port is placed close to the scope port; this allows better exposure in placing the leads. Short 10- to 12-mm ports are sufficient for the surgical tools and scope. Single-lung ventilation is started and, if necessary, supplemented with carbon dioxide insufflations at pressures of approximately 8 to 10 cm H2O. The procedure is then performed in the same fashion as for minithoracotomy by opening the pericardium 1 cm parallel to the phrenic nerve. If stay sutures are necessary, they can be either brought out through the ports or anchored internally on adjoining chest wall tissue. The goal is to place the lead posterior to the obtuse marginal artery, adjacent to the anterior aspect of the left atrial appendage. The lead is screwed in either by using the Medtronic tool or by placing a more posterior port to allow direct screwing in at right angles to the left ventricular surface (Fig 4). The leads are then brought out through the second intercostal space port and tunneled to the pacemaker generator pocket and connected. Hemostasis is obtained, and a size 10 Jackson-Pratt drain is placed in the left pleural space through the auxiliary port.
Anesthesia preparation and monitoring for the robotically assisted procedure are the same as described for the previous techniques. The patient should be placed in a full left posterolateral thoracotomy position. The da Vinci Robotic Surgical System (Intuitive Surgical Inc, Sunnyvale, CA) is used. Working ports should be placed in the posterior axillary line and adjusted caudad or cephalad, depending on the angle to the left ventricle, to allow placement of the screw-in lead. Flexibility in port positions is important and should be adjusted on the basis of individual chest wall and cardiac anatomy. Often, the fifth intercostal space is used for the right instrument, the seventh space for the camera, and the ninth space for the left instrument (Fig 5). Leads are passed through an auxiliary port on the sixth space and fixed similarly to the thoracoscopic method, but less space is needed for instrument manipulation. Both leads are tunneled as far anterior as possible (Fig 6) to reach the generator pocket with ease. The air is evacuated from the pleural space, and a Jackson-Pratt drain is placed. The patient is reprepared and redraped in the supine position to establish hookup to the generator. The patient is frequently extubated in the operating room.
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Fig 6. Robotically assisted placement, showing the tunneling of the leads as far anteriorly as possible after implantation.
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The selection of the best implantation site is determined by echocardiography with tissue Doppler imaging in combination with intraoperative electrophysiological measurements. The target is the posterolateral wall of the left ventricle in most patients [1]. Areas of ischemic and scarred myocardium are avoided whenever the latter is covered with fatty or fibrous tissue. Just after implantation, the myocardial performance with biventricular pacing is assessed by transesophageal echocardiography.
Patients spend brief periods of time in the intensive care unit and then are transferred to the regular nursing floor. The chest drain is removed on the first postoperative day if there is minimal output. Usually, a period of adjustment of medications is required at this point, as are pain management protocols. Usually, an echocardiography-guided optimization of the biventricular pacing is performed on the second postoperative day.
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Comment
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Several prospective studies [2–4] have proven the benefit of biventricular pacing for improving ventricular function, exercise capacity, and quality of life. Because of limitations of the transvenous method, epicardial left ventricular lead placement is often a rescue procedure in patients with ventricular dyssynchrony associated with congestive heart failure. There are some advantages related to its safety and shorter implant time. Furthermore, it allows visual, electrophysiologic, and echocardiographic selection of the best pacing site and multiplicity of pacing sites. The success of minimally invasive surgical procedures fulfills the objectives of low risk and similar or superior results [5].
From October 2002 to July 2003, 34 end-stage heart failure patients underwent epicardial left ventricular lead implantation. Minithoracotomy was performed in 16 patients (47%), VATS in 14 patients (41.2%), and robotically assisted procedures in 4 patients (11.8%). The mean hospital length of stay was 4.8 ± 3.3 days. There were no deaths. Postoperative complications included nondialysis renal failure in 2 patients (5.8%), atrial fibrillation in 3 (8.8%), nonsustained ventricular tachycardia in 3 (8.8%), and decompensated heart failure in 2 (5.8%). Improvements were observed in New York Heart Association functional class, QRS duration, lead sensing, and impedance in the postoperative period.
My colleague and I believe that minimally invasive surgical alternatives for left ventricular epicardial lead implantation in heart failure patients are a viable option and can be helpful in the treatment of this complex disease.
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References
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- 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]
- Young JB, Abraham WT, Smith AL, et al. Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure. The MIRACLE ICD-Trial JAMA 2003;289:2685-2694.[Abstract/Free Full Text]
- Auricchio A, Stellbrink C, Sack S, et al. Long-term clinical effect of hemodynamically optimized cardiac resynchronization therapy in patients with heart failure, and ventricular function delay J Am Coll Cardiol 2002;39:2026-2033.[Abstract/Free Full Text]
- Linde C, Braunschweig F, Gadler F, Bailleul C, Daubert JC. Long-term improvements in quality of life by biventricular pacing in patients with chronic heart failureresults from the multisite stimulation in cardiomyopathy study (MUSTIC). Am J Cardiol 2003;91:1090-1095.[Medline]
- DeRose JJ, Ashton RC, Belsley S, et al. Robotically assisted left ventricular epicardial lead implantation for biventricular pacing J Am Coll Cardiol 2003;41:1414-1419.[Abstract/Free Full Text]
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Abstract
Introduction
