Alternative Method for Cardiac Resynchronization: Transapical Lead Implantation

doi:10.1016/j.athoracsur.2008.04.080

The Annals of Thoracic Surgery

Volume 87, Issue 2, February 2009, Pages 650-652

https://doi.org/10.1016/j.athoracsur.2008.04.080 Get rights and content

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.

Section snippets

Technique

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

Comment

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,

References (4)

W.T. Abraham et al.
Multicenter Insync Randomized Clinical EvaluationCardiac resynchronization in chronic heart failure
N Engl J Med
(2002)
B.M. Gelder et al.
Transseptal endocardial left ventricular pacing: An alternative technique for coronary sinus lead placement in cardiac resynchronization therapy
Heart Rhythm
(2007)

There are more references available in the full text version of this article.

Cited by (18)

Epicardial leads in adult cardiac resynchronization therapy recipients: A study on lead performance, durability, and safety
2015, Heart Rhythm
Citation Excerpt :
With the increasing number of CRT recipients, the number of patients in whom transvenous LV lead placement is impossible continues to rise.14 Consequently there has been a growing interest in alternatives for transvenous lead placement, such as video-assisted thoracoscopic LV lead placement and transapical and transseptal endocardial lead implantation.15–17 Moreover, there has been a renewed interest in epicardial LV leads, with the development of novel implantation techniques and new lead technologies.8,18
Transvenous left ventricular (LV) lead placement for cardiac resynchronization therapy–defibrillator (CRT-D) delivery is unsuccessful in 8% to 10% of cases. These patients might benefit from an epicardial lead. However, data on long-term epicardial lead performance are scarce. Furthermore, extracting an epicardial lead requires a rethoracotomy.
The purpose of this study was to determine data on almost a decade of experience with epicardial leads and investigate the safety of partially leaving this lead in place after device infection.
All adult patients receiving an epicardial lead (Medtronic CapSure Epi, model 4968) for CRT-D in the Leiden University Medical Center were included. Leads were implanted during a standalone procedure or in combination with other cardiothoracic procedures. Electrical lead parameters were assessed at implantation and every 6 months thereafter. In case of device infection the epicardial lead was cut off parasternal, just outside the thoracic cavity, leaving the distal part of the lead in place.
Two-hundred sixteen patients were included with a median follow-up of 3 years (25th–75th percentile 1.0–5.5). LV pacing threshold decreased within 6 months after implantation [1.1 V (95% confidence interval [CI] 0.9–1.2) vs 0.8 V (95% CI 0.7–0.9), P = .01] and stabilized thereafter. Mean LV electrogram was 15.2 ± 7.5mV, and average lead impedance was 633.5 ± 174.0 Ω. Five-year cumulative incidence was 1.6% for lead failure and 9.6% for device infection. The retained epicardial lead caused skin erosion in 3 patients and fistula formation in 1.
This study demonstrates that epicardial LV leads have an excellent long-term performance. Partially retaining the lead after device infection was associated with a risk of reinfection with limited long-term clinical implications for the patient.
Long-Term Performance of Epicardial versus Transvenous Left Ventricular Leads for Cardiac Resynchronization Therapy
2023, Journal of Clinical Medicine
Long-term cerebral thromboembolic complications of transapical endocardial resynchronization therapy
2017, Journal of Interventional Cardiac Electrophysiology
Evaluation of wireless stimulation of the endocardium, WiSE, technology for treatment heart failure
2016, Expert Review of Medical Devices
Endocardial left ventricular lead placement from the left subclavian vein approach
2014, Europace
Endocardial pacing: The wave of the future?
2012, Current Cardiology Reports

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How to do itAlternative Method for Cardiac Resynchronization: Transapical Lead Implantation

Section snippets

Technique

Comment

Multicenter Insync Randomized Clinical EvaluationCardiac resynchronization in chronic heart failure

N Engl J Med

Transseptal endocardial left ventricular pacing: An alternative technique for coronary sinus lead placement in cardiac resynchronization therapy

Heart Rhythm

How to do it
Alternative Method for Cardiac Resynchronization: Transapical Lead Implantation