title: Nontraditional surgical approaches for implantation of pacemaker and cardioverter defibrillator systems in patients with limited venous access.
abstract: BACKGROUND
  Indications for placement of implantable cardioverter-defibrillators (ICD) and pacemakers have expanded, and traditional transvenous implantation may not be feasible in patients with aberrant anatomy or venous obstruction. In these settings, successful lead placement has required innovative surgical approaches. A case series of successful placement of these systems in challenging patients is presented.
  
  
  METHODS
  A 2-year retrospective study of patients undergoing placement of minimally invasive epicardial pacing leads or ICD coils was performed.
  
  
  RESULTS
  Eleven patients underwent minimally invasive surgical placement of leads or coils. None were converted to open sternotomy. One required extension to minianterior thoracotomy. Causes of intravenous placement failure included aberrant anatomy with failure to access coronary sinus in 9 and venous occlusion in 2. Four patients had previous operations through a median sternotomy. Procedures included left video-assisted thoracoscopic (VATS) placement of a left ventricular epicardial lead in 8, left VATS conversion to minianterior thoracotomy left ventricular epicardial lead placement in 1, left VATS placement of ICD coil in 1, subxiphoid placement of a right ventricular epicardial lead in 1, subxiphoid ICD coil in 2, and subcutaneous ICD coil placement in 3. Mean hospitalization was 4.6 days. Postoperative hypotension and pulmonary edema occurred in 27% of patients. No patients died.
  
  
  CONCLUSIONS
  Conventional transvenous lead implantation may be difficult or impossible in some patients with aberrant or occluded venous access. Novel surgical approaches with the use of minimally invasive procedures can establish optimally functional pacing and ICD systems without sternotomy and low associated morbidity.
authors: Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona 85043, USA. jaroszewski.dawn@mayo.edu
authors: Dawn E
authors: DE
authors: Jaroszewski
authors: Gregory T
authors: GT
authors: Altemose
authors: Luis R
authors: LR
authors: Scott
authors: Komandoor
authors: K
authors: Srivasthan
authors: Patrick A
authors: PA
authors: Devaleria
authors: Jesse
authors: J
authors: Lackey
authors: Francisco A
authors: FA
authors: Arabia
mesh_terms: D000368:Aged; D001145:Arrhythmias, Cardiac / Q000175:diagnosis / Q000628:therapy; D006328:Cardiac Catheterization / Q000379:methods*; D002406:Catheterization, Peripheral / Q000379:methods; D015331:Cohort Studies; D003251:Constriction, Pathologic / Q000473:pathology; D017147:Defibrillators, Implantable; D004567:Electrodes, Implanted; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000175:diagnosis / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D010138:Pacemaker, Artificial; D019919:Prosthesis Implantation; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods; D016896:Treatment Outcome; D014680:Veins / Q000473:pathology*; D055815:Young Adult