Surgical epicardial left ventricular lead versus coronary sinus lead placement in biventricular pacing.
OBJECTIVE
Biventricular pacing has demonstrated improvement in cardiac function in treating congestive heart failure (CHF). Two different operative strategies (coronary sinus vs. epicardial stimulation) for left ventricular (LV) pacing were compared.


METHODS
Since April 1999, a total of 86 patients (pts, age: 63+/-10 years) with depressed systolic LV function (mean ejection fraction 24+/-9%), left bundle-branch-block (mean QRS 182+/-22 ms) and congestive heart failure NYHA III or higher were enrolled. For biventricular stimulation coronary sinus (CS) leads were placed in 79 pts. Nine of these devices were converted to surgical epicardial LV-leads, because of CS-lead failure. In 7 patients epicardial LV-leads were initially implanted surgically, accounting for a total of 16 pts with surgical placed epicardial steroid-eluting LV-leads. For these, a limited left-lateral thoracotomy (7+/-4 cm) was used. Thirty-three (38%) pts had an indication for a defibrillator. The mean follow-up time was 16.4+/-15.4 months (0.1-45 months), representing 107.1 patient-years.


RESULTS
In the biventricular pacing mode, QRS duration decreased to 143+/-16 ms (P<0.001). Threshold capture of the CS-leads increased significantly compared to surgically placed epicardial leads (18 month control: 2.2+/-1.4V/0.5 ms vs. 0.7+/-0.3V/0.5 ms), which had no increase in threshold (P<0.001). At the 18 month follow-up 7 CS-leads had a threshold of >4V/0.5 ms vs. epicardial leads which were under 1.1V/0.5 ms, except for one (1.8V/0.5 ms). After CS-lead implantation 25 LV-lead related complications occurred, (failed implantation, CS-dissection, loss of pacing capture, diaphragm stimulation or lead dislodgment), vs. one dislodgement after surgical epicardial lead placement (P<0.05). Correct lead positioning (obtuse marginal branch area) was achieved in all surgical epicardial placements but only in 70% with CS-leads (P<0.03). In the follow up period, 9 pts died (4 cardiac related). Heart transplantation was necessary in 4 pts due to deterioration of the cardiomyopathy.


CONCLUSIONS
Surgical epicardial lead placement revealed excellent long-term results and a lower LV-related complication rate compared to CS-leads. Although, the approach via limited thoracotomy for biventricular pacing is associated with 'more surgery', it is a safe and reliable technique and should be considered as an equal alternative.
Mair
Helmut
H
Department of Cardiac Surgery, University of Munich, Marchioninistr. 15, 81377 Munich, Germany. helmut.mair@med.uni-muenchen.de
Sachweh
Joerg
J
Meuris
Bart
B
Nollert
Georg
G
Schmoeckel
Michael
M
Schuetz
Albert
A
Reichart
Bruno
B
Daebritz
Sabine
S
D002037:Bundle-Branch Block / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D002304:Cardiac Pacing, Artificial / Q000379:methods*; D004567:Electrodes, Implanted; D006325:Heart Atria / Q000503:physiopathology / Q000601:surgery; D006333:Heart Failure / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008875:Middle Aged; D010138:Pacemaker, Artificial; D010496:Pericardium / Q000503:physiopathology / Q000601:surgery; D011183:Postoperative Complications / Q000503:physiopathology; D012849:Sinoatrial Node / Q000503:physiopathology / Q000601:surgery; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*