Ann Thorac Surg 2009;87:650-652. doi:10.1016/j.athoracsur.2008.04.080
© 2009 The Society of Thoracic Surgeons
How To Do It
Alternative Method for Cardiac Resynchronization: Transapical Lead Implantation
Imre Kassai, MDa,
Csaba Foldesi, MDa,
Andrea Szekely, MDa,
Tamas Szili-Torok, MD, PhDa,b,*
a Gottsegen Gyorgy Hungarian Institute of Cardiology, Budapest, Hungary
b Department of Clinical Electrophysiology, Thoraxcentre, Erasmus Medical Center, Rotterdam, the Netherlands
Accepted for publication April 23, 2008.
* Address correspondence to Dr Szili-Torok, Department of Clinical Cardiac Electrophysiology, Thoraxcentre, Erasmus Medical Center, Rotterdam, 3000 CA, the Netherlands (Email: t.szilitorok{at}erasmusmc.nl).
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Abstract
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Alternative methods are necessary for cardiac resynchronization therapy when coronary sinus lead implantation fails. We aim to describe a fundamentally new approach using transapical implantation of an active fixation endocardial pacing lead. This technique is based on direct puncture of the left ventricular apex using the standard Seldinger technique. The tip of the lead is positioned with intracavital navigation under fluoroscopy. This method offers advantages for cardiac resynchronization because it is minimally invasive, provides endocardial pacing, and does not involve the mitral valve.
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Introduction
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Coronary sinus lead placement for transvenous left ventricular pacing in cardiac resynchronization therapy has a failure rate at implant and at short-term follow-up of between 10% and 15% [1]. For these patients, epicardial pacing lead implantation is the most frequently used alternative. Recent data supports endocardial lead implantation through the atrial septum and the mitral valve because this method provides further hemodynamic advantages [2]. Trans-septal cardiac resynchronization therapy carries a significant risk for device-related infective endocarditis of the mitral valve, and this condition can only be treated with a very high-risk surgical lead extraction and repair or replacement of the valve. On this basis we aimed to develop a fundamentally new approach for endocardial left ventricular (LV) lead implantation.
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Technique
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The patient should be prepared for the operation with general anesthesia using a regular intratracheal intubation and should be positioned for an infraclavicular incision, as well as a small left thoracotomy. The apical process can be performed with video-assisted thoracoscopic surgery. However, selective bronchial intubation is needed in the latter case, and the port sites should also be included in the surgical field. Initial transthoracic echocardiography is used to locate the LV apex. The use of external defibrillator pads, placed antero-posterior is recommended. Inside the chest, a small pericardiotomy is performed above the LV apex. Any type of standard active fixation endocardial pacing lead can be inserted in the LV cavity through the apex (Fig 1B). We used one of the thinnest commercially available bipolar electrodes to reduce traumatic effect during insertion. A standard Seldinger technique with a peel-away sheath is recommended for this procedure. When undertaking this procedure, we recommend that the following steps should be followed: puncture the apex with a needle, insert the guidewire through the needle, remove the needle out of the apex, dilate the apex hole with a peel-away sheath inserted over the guidewire, remove the guidewire, insert the pacing electrode into the LV cavity through the sheet, and remove the peel-away sheet. Hemorrhaging from the left ventricle can be controlled with one or two 5-0 or 4-0 monofilament purse-string sutures around the puncture point. It is recommended to place the sutures before puncturing the apex, and to apply them as tourniquets. If the tissue quality of the apex requires pledgeted sutures, we recommend pledge material in the surrounding pericardium. Fluoroscopy is necessary for the intracavital navigation and endocardial fixation of the electrode at the optimal pacing site for cardiac resynchronization therapy. To reach the target area, a "J"-shaped electrode guidewire is useful. After effective endocardial fixation of the lead tip, the pacing and sensing measurements should be measured. The acceptable pacing threshold for this kind of electrode is less than 1 V. R-wave amplitude for sensing in this electrode should be more than 5 mV. An approximate 90° electrode loop is recommended inside the LV cavity. Purse-string sutures in the apex should be tied to restrict the movement of the electrode through the apex, and they should also be gently tied to the body of the electrode to stabilize position. Before closing the chest wall, the lead should be subcutaneously tunneled through to the generator pocket. Before connecting to the generator, the lead connector should be cleaned removing all subcutaneous tissue. After LV electrode implantation, the patient should be anticoagulated with a target anticoagulation level identical to mechanical valve prostheses.
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Fig 1. (A) Postoperative chest X-rays from (above) antero-posterior and from (below) lateral projections. (B) Photograph of the lead tip with endpoints of the screw's movement. (C) Intraoperative photograph of mini-thoracotomy approaching the apical region of the heart, showing transapical lead insertion into the left ventricle. (AP = antero-posterior; LAO = left anterior oblique projection.)
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Five end-stage heart failure patients underwent transapical LV lead implantation (Table 1). All patients gave written informed consent before the procedure. There were no major and minor complications related to this novel approach. During the follow-up period, 4 of the 5 patients responded favorably to the treatment. One patient's symptoms did not change; however, the numbers of hospitalizations are decreased and her New York Heart Association functional class improved. Technically, all implanted leads are working properly. One episode of self-terminating ventricular tachycardia was detected by one of the implantable cardioverter defibrillators.
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Comment
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To achieve cardiac resynchronization therapy, alternative methods are necessary for patients in which coronary sinus lead implantation has failed. Epicardial pacing lead implantation is the most frequently used alternative, although this approach requires heart surgery. Due to LV dilatation, reaching the target area and pacing the most delayed segment of the lateral wall can be difficult or in some cases impossible. Pericardial adhesions, which can be fairly common in this group of patients, can hide the location of epicardial coronaries. Avoiding the damage of important vessels, while inserting the epicardial lead, is a challenging process. Furthermore, epicardial pacing seems to be less optimal than endocardial pacing. An activation sequence originating from the endocardial surface has advantages over epicardial stimulation. Endocardial stimulation has shown to be associated with a greater aortic and mitral time velocity integral, an increased left ventricular fractional shortening, and an improvement in the regional electromechanic delay in comparison with epicardial stimulation [2]. There are studies showing endocardial leads that were implanted through the atrial septum and mitral valve that have also achieved similar results [2, 3]. We strongly believe that additional risks are not negligible. When a foreign body enters from the right atrium into the left side of the heart and is in close and permanent contact with the mitral valve, it increases the risk of mitral endocarditis [4]. The transapical method we developed can overcome most of the previously mentioned potential problems. Furthermore, this provides an alternative for patients who are very burdened. The advantages of this transapical technique are that it is minimally invasive, provides endocardial pacing, and avoids problems associated with contact with the mitral valve.
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Acknowledgments
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We thank Richard Alloway, RN, for language revision of the article.
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References
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- Abraham WT, Fisher WG, Smith AL, et al. MIRACLE Study Group Multicenter Insync Randomized Clinical Evaluation. Cardiac resynchronization in chronic heart failure. N Engl J Med 2002;346:1845-1853.[Abstract/Free Full Text]
- Gelder BM, Scheffer MG, Meijer A, Bracke FA. Transseptal endocardial left ventricular pacing: An alternative technique for coronary sinus lead placement in cardiac resynchronization therapy Heart Rhythm 2007;4:454-460.[Medline]
- Nuta B, Lines I, Macintyre I, Haywood GA. Biventricular ICD implant using endocardial LV lead placement from the left subclavian vein approach and transseptal puncture via the transfemoral route Europace 2007;9:1038-1040.[Abstract/Free Full Text]
- Kassai I, Szili-Torok T. Concerns about the long-term outcome of transseptal cardiac resynchronization therapy: what we have learned from surgical experience Europace 2008;10:121-122.[Free Full Text]
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Abstract
Introduction
