Ann Thorac Surg 2006;81:407
© 2006 The Society of Thoracic Surgeons
Minimally Invasive Surgical Placement of Left Ventricular Epicardial Lead: Letter 1
Gianluigi Bisleri, MD,
Tomaso Bottio, MD, PhD,
Claudio Muneretto, MD
Division of Cardiac Surgery, University of Brescia Medical School, UDA Cardiochirurgia Spedali Civili, P.le Spedali Civili, 1, Brescia, 25123 Italy
To the Editor:
We read with interest the article of Doll and colleagues  about the minimally invasive use of a novel tool for left ventricular lead placement; nevertheless, their report raises several concerns.
First, the authors state that the thoracotomy approach avoids the drawbacks of thoracoscopy in terms of hemodynamic instability. In our thoracoscopic experience, a more careful regulation of the CO2 insufflation (maintaining lower pressures than conventional thoracoscopic procedures, ie, 4 to 5 mm Hg) together with the posterolateral positioning of the patient and the trocars , allow an optimal visualization of the ventricular region at the level of the first/second obtuse marginal branch without a significant hemodynamic compromise. Therefore we believe that a conventional thoracoscopic procedure (without robotic assistance) is feasible with cost-effectiveness comparable with that of a mini-thoracotomy, but with significant reduced postoperative pain discomfort and improved aesthetic results.
It would also be interesting to know whether the tool has the capability to re-load the lead once screwed into the heart in case any need should occur to reposition it, (eg, in case of lead malpositioning) without direct access to the ventricular surface, otherwise the tool would have no advantage with respect to the conventional epicardial lead.
Finally, we share the concerns of Mickleborough  about the optimal lead positioning; several authors previously stressed that it is mandatory to technically locate and position the pacing leads in the appropriate site for the success of cardiac resynchronization therapy . In addition, no specific information is provided about the preoperative evaluation of potentially scarred areas in the posterolateral regions of the 3 patients with ischemic cardiomyopathy, therefore making lead positioning in that area not useful to improve the dyssynchronous contractility.
- Doll N, Opfermann UT, Rastan AJ, et al. Facilitated minimally invasive left ventricular epicardial lead placement Ann Thorac Surg 2005;79:1023-1025.[Abstract/Free Full Text]
- DeRose JJ, Ashton RC, Belsley S, et al. Robotically assisted left ventricular lead implantation for biventricular pacing J Am Coll Cardiol 2003;41:1414-1419.[Medline]
- Mickleborough L. Invited commentary Ann Thorac Surg 2005;79:1025.[Free Full Text]
- Mehra MR, Greenberg BH. Cardiac resynchronization therapycaveat medicus!. J Am Coll Cardiol 2004;43:1145-1148.[Medline]
- Butter C, Auricchio A, Stellbrink C, Fleck E, Ding J, Yu Y, et al. Effect of resynchronization therapy stimulation site on the systolic function of heart failure patients Circulation 2001;104:3026-3029.
- Dekker ALAJ, Phelps B, Dijkman B, et al. Epicardial left ventricular lead placement for cardiac resynchronization therapyoptimal pace site selection with pressure-volume loops. J Thorac Cardiovasc Surg 2004;127:1641-1647.[Abstract/Free Full Text]