Minimally invasive left ventricular epicardial lead placement: surgical techniques for heart failure resynchronization therapy.
BACKGROUND
Epicardial lead placement for biventricular pacing is often a rescue procedure after failed coronary sinus cannulation. This study aims to determine perioperative and early postoperative outcome of minimally invasive left ventricular lead placement as a management strategy for heart failure, comparing minithoracotomy and endoscopic approaches.


METHODS
From October 2002 through October 2003, 41 patients underwent minimally invasive left ventricular lead placement, 23 (56%) by minithoracotomy and 18 (44%) endoscopically. Thirty-one (76%) were males, 19 (46%) had previous cardiac surgery, 21 (51%) had ischemic cardiomyopathy, 17 (41%) were in New York Heart Association class III or IV, and 28 (65%) had implantable cardioverter-defibrillators.


RESULTS
There were no in-hospital deaths, intraoperative complications, or failures to implant the left ventricular lead. Median operative time was longer for the endoscopic approach (188 minutes) than for minithoracotomy (151 minutes; p = 0.006). Preoperatively, the endoscopic group had more mitral regurgitation (median, 2.5 versus 1.0, respectively; p = 0.009). QRS duration was shorter postoperatively (mean change from preoperative, -32 +/- 24 ms; p < 0.0001); this change was unrelated to surgical approach. Impedance also was less postoperatively (mean change, -490 +/- 300 ohms; p < 0.0001), and the change was unrelated to surgical approach. Changes were greater the larger their preoperative values (p < 0.0001). Threshold increased with follow-up time (adjusted p < 0.0001), but impedance decreased (adjusted p = 0.0009); these trends were similar for both approaches. No changes were evident in left ventricular dimensions.


CONCLUSIONS
Minimally invasive left ventricular epicardial lead placement is safe and effective, offering selection of the best pacing site with minimal morbidity; it can be considered a primary option for resynchronization therapy.
Navia
José L
JL
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA. naviaj@ccf.org
Atik
Fernando A
FA
Grimm
Richard A
RA
Garcia
Mario
M
Vega
Pablo Ruda
PR
Myhre
Ulf
U
Starling
Randall C
RC
Wilkoff
Bruce L
BL
Martin
David
D
Houghtaling
Penny L
PL
Blackstone
Eugene H
EH
Cosgrove
Delos M
DM
D000368:Aged; D002304:Cardiac Pacing, Artificial / Q000379:methods; D015150:Echocardiography, Doppler; D005260:Female; D006333:Heart Failure / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006339:Heart Rate / Q000502:physiology*; D006801:Humans; D007362:Intensive Care Units; D007854:Lead; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000453:epidemiology; D016343:Monitoring, Intraoperative; D010138:Pacemaker, Artificial; D011183:Postoperative Complications / Q000145:classification / Q000453:epidemiology; D012371:Robotics; D014741:Video Recording
D007854:Lead