Novel approach to epicardial pacemaker implantation in patients with limited venous access.
BACKGROUND
Limited venous access in certain patients increases the procedural risk and complexity of conventional transvenous pacemaker implantation.


OBJECTIVE
The purpose of this study was to determine a minimally invasive epicardial approach using pericardial reflections for dual-chamber pacemaker implantation in patients with limited venous access.


METHODS
Between June 2006 and November 2011, 15 patients underwent epicardial pacemaker implantation. Procedures were performed through a minimally invasive subxiphoid approach and pericardial window with subsequent fluoroscopy-assisted lead placement. Mean patient age was 46.4 ± 15.3 years (9 male [(60.0%], 6 female [40.0%]). The new surgical approach was used in patients determined to have limited venous access due to multiple abandoned leads in 5 (33.3%), venous occlusion in 3 (20.0%), intravascular retention of lead fragments from prior extraction in 3 (20.0%), tricuspid valve vegetation currently under treatment in 2 (13.3%), and unrepaired intracardiac defects in 2 (13.3%).


RESULTS
All procedures were successful with no perioperative complications or early deaths. Mean operating time for isolated pacemaker implantation was 231.7 ± 33.5 minutes. Lead placement on the superior aspect of right atrium, through the transverse sinus, was possible in 12 patients. In the remaining 3 patients, the atrial lead was implanted on the left atrium through the oblique sinus, the postcaval recess, or the left pulmonary vein recess. None of the patients displayed pacing or sensing dysfunction, and all parameters remained stable throughout the follow-up period of 36.8 ± 25.1 months.


CONCLUSIONS
Epicardial pacemaker implantation through pericardial reflections is an effective alternative therapy for those patients requiring physiologic pacing in whom venous access is limited.
Department of Cardiovascular Surgery, Heart Institute (InCor)-Clinics Hospital of the University of Sao Paulo Medical School, Sao Paulo, Brazil. Electronic address: rcosta@incor.usp.br.
Roberto
R
Costa
Mauricio
M
Scanavacca
Kátia Regina
KR
da Silva
Martino
M
Martinelli Filho
Roger
R
Carrillo
D000328:Adult; D000368:Aged; D054537:Atrioventricular Block / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D004452:Echocardiography; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D010138:Pacemaker, Artificial; D010496:Pericardium; D012189:Retrospective Studies; D013318:Stroke Volume; D016896:Treatment Outcome
Artificial pacemaker; Central venous occlusion; Endocarditis; Epicardial lead; Implanted electrodes; Pericardial reflections; Subxiphoid; Surgical procedures