Ann Thorac Surg 2006;81:407-408
© 2006 The Society of Thoracic Surgeons
Correspondence
Minimally Invasive Surgical Placement of Left Ventricular Epicardial Lead: Letter 2
Helmut Mair, MD,
Ingo Kaczmarek, MD,
Martin Oberhoffer, MD,
Sabine Daebritz, MD
Cardiac Surgery, University of Munich, Marchioninistr 15, Munich, 81377 Germany
(Email: helmut.mair{at}med.uni-muenchen.de).
To the Editor:
Doll and associates [1] recently described epicardial left ventricular (LV) lead placement with the Medtronic 5071 Epicardial pacing lead (Medtronic, Inc, Minneapolis, MN) through an anterolateral mini-thoracotomy facilitated by using the Medtronic 10626 lead implant tool for cardiac resynchronization therapy in 7 patients with transvenous implantation failure. However, we have some additional comments.
Metal rip spreaders as used in the presented study, are associated with marked postoperative chest pain, even if applied with only slight retraction. We experienced this as well in our first serious of mini-thoracotomies. Therefore, we changed to a Soft Tissue Retractor (Cardiovations, Ethicon GmbH, Germany) that provides enough space but does not affect rips (Fig 1). Chest pain was significantly reduced since then.
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Fig 1. Surgical epicardial placement of a Medtronic 5071 screw-in lead that was facilitated by the Medtronic 10626 implantation tool (Medtronic, Inc, Minneapolis, MN) through a 5-6 cm left lateral, midaxillary mini-thoracotomy spread with a soft tissue retractor (Cardiovations, Ethicon GmbH, Germany).
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We agree that techniques such as the mini-thoracotomy are best suitable for widespread use of surgical epicardial lead placement. However, in our opinion a left lateral, midaxillary mini-thoracotomy provides more direct visualization to the posterolateral wall than an anterior thoracotomy, and therefore it is advantageous for LV lead placement. Even with the malleable Medtronic 10626 implantation tool [2], this approach is superior to reach the intended target area that is anatomically posterolaterally near the origin of the obtuse marginal branch. This applies even more in lack of thoracoscopic support.
We recently demonstrated that surgical epicardial lead placement is superior to transvenous lead placement through the coronary sinus with regard to freedom from LV lead-related adverse events, threshold capture, and especially achievement of the intended optimal target site [3]. But surgical approaches also have drawbacks such as intubation or operative trauma, and so forth. Therefore, the development of lesser invasive techniques, such as thoracoscopic or robotic approaches, is mandatory and should not be only considered time and money consuming as stated in the article [1] neglecting the advantages of these techniques. We need the best and minimal invasive techniques that decrease surgical drawbacks on one hand, but have no negative impact on success rates on the other hand.
Finally, in the article of Doll and associates [1] the Medtronic 5071 screw-in lead was accidentally described as steroid eluting. In fact it is a nonsteroid eluting lead, which might cause reduced longevity of the lead and thus hazard the widespread use of the Medtronic Epicardial System (10626 implantation tool and 5071 screw-in lead) in the future. Advancements and prototypes of the next generation of surgical epicardial leads are already in clinical testing with promising results.
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References
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- 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]
- Mair H, Jansens JL, Lattouf OM, Reichart B, Dabritz S. Epicardial lead implantation techniques for biventricular pacing via left lateral mini-thoracotomy, video-assisted thoracoscopy, and robotic approach Heart Surg Forum 2003;6(5):412-417.[Medline]
- Mair H, Sachweh J, Meuris B, et al. Surgical epicardial left ventricular lead versus coronary sinus lead placement in biventricular pacing Eur J Cardiothorac Surg 2005;27(2):235-242.[Abstract/Free Full Text]
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