Abstract

Cardiac resynchronization therapy is a promising therapeutic option for patients with end-stage heart failure. The preferred method for left ventricular lead implantation is the percutaneous access through the coronary sinus. However, this technique may impose certain technical difficulties due to suboptimal lead positioning. In such cases, a video-assisted thoracoscopic epicardial approach may be a good alternative. To date, video-assisted left ventricular epicardial lead implantation from two or three port incisions have been described. Herein, we present the first successful left ventricular epicardial lead implantation through a simplified single-port video-assisted thoracoscopy technique in Turkey.

Prognosis of end-stage heart failure is still poor for many patients, despite the overwhelming advances in pharmacological treatment strategies. Cardiac resynchronization therapy (CRT) is a promising therapeutic option for this subgroup of patients. The mechanism behind the CRT therapy is resynchronization of the ventricular activation sequence and, thereby, improving ventricular pumping performance by enhancing coordination of atrioventricular timing.[1]

Although the usual approach for left ventricular (LV) lead implantation for CRT therapy is the percutaneous access via the coronary sinus, this method may impose certain technical difficulties, mainly due to suboptimal lead positioning. In such cases, lead placement requires surgical methods. In addition to open surgical approaches, minimally invasive thoracoscopic methods have been designed for CRT implantation.[2] Almost all of these techniques require two or three port incisions for video-assisted thoracoscopic surgery (VATS) insertion of the LV lead. Herein, we, for the first time, present a new and simplified approach for LV lead implantation using a single-port VATS technique.

Case Presentation

A 62-year-old man with advanced heart failure with the New York Heart Association (NYHA) Class IV was admitted to our hospital with complaints of exertional dyspnea and reduced exercise capacity. His medical history revealed, dual chamber deviceimplantable cardioverter defibrillator (DDD-ICD) implantation 18 months ago. Echocardiography revealed dilated cardiomyopathy and moderate-to-high mitral regurgitation. The LV ejection fraction was 31%, the QRS duration was 158 ms, and the LV end-diastolic diameter was 74 mm. There was no severe valvular disease. Based on diagnostic testing, CRT therapy was scheduled for the patient. Due to the failure of intravenous LV lead implantation attempt, however, a thoracoscopic approach was planned. A written informed consent was obtained from the patient.

The intervention was performed under general anesthesia with a double-lumen tube for single lung ventilation. The patient was placed in the right lateral decubitus position with a slight posterior tilt. A 3-cm-long skin incision was performed (left fifth intercostal space, midaxillary line), the intercostal muscles were divided, and a XS Alexis® retractor (Applied Medical, Rancho Santa Margarita, CA, USA) was positioned. The camera and endoscopic instrument were inserted through the Alexis® r etractor. A 2 -cm pericardiotomy was performed with an endoscissor to expose the posterolateral wall of the LV. The sutureless LV lead and introducer (Myodex, Bipolar 1084 T/54 St. Jude Medical Inc., MN, USA) were screwed into the posterolateral wall of the LV through the Alexis® retractor and the introducer was removed. Following confirmation of the thresholds, the proximal end was passed through the subcutaneous tunnel created over xiphoid process and connected to the generator in the previously reopened pacemaker pocket. The lead was loosely placed in the thoracic cavity to prevent traction of the lead after re-expansion of the lung. The lung was slowly ventilated and lead position was checked. The retractor was removed and the chest tube was inserted through the same incision (Figure 1). The position of the LV lead was confirmed by chest X-ray after the procedure (Figure 2). The postoperative electrocardiogram showed an improvement in the QRS duration with 137 ms and the ventricular contractions were synchronous. The chest tube was removed in the first postoperative day and the patient was discharged in the third postoperative day.

Figure 1. Closed single-port incision with the chest tube.

Figure 2. The position of the left ventricular lead confirmed by the postoperative chest X-ray.

Discussion

Cardiac resynchronization therapy is a pacemakerbased therapy for advanced heart failure which enhances ventricular function by biventricular stimulation. Posterolateral wall of the LV is considered the most optimal area for the lead implantation. Although percutaneous approach seems feasible in most cases, it has a failure rate of 8% depending on the venous and coronary sinus anatomy, technical difficulties in reaching proper anatomical area and ineffective pacing due to the scar burden in the lead placement area. This procedure also requires prolonged exposure to X-ray, particularly in case of suboptimal anatomy which poses a risk both for the patient and the heart team. Also, lethal complications such as coronary sinus perforation may occur, although very rarely.[3,4] Accordingly, surgical approach may be required in some subgroup of patients.

Surgical positioning of LV lead has the advantage of direct visualization and proper selection of the ideal surface for implantation which leads to higher success rates in some series. However, open thoracotomy is considerably painful and carries a high rate of morbidity. In recent years, VATS has become a routine procedure in thoracic surgical practice.[5] The main advantages of VATS include better visualization, less trauma and pain, more rapid recovery, short hospital stay, and improved cosmetic results.[5] It also obviates X-ray exposure and contrast agent use. Nevertheless, VATS has some drawbacks over both transvenous and open thoracotomy approaches. First, VATS requires general anesthesia and single lung ventilation. Second, pleural or pericardial adhesions may hinder the operation, resulting in conversion to open thoracotomy. Finally, epicardial lacerations may occur during intrathoracic manipulation of the instruments.

Gabor et al.[5] used two-port VATS approach for CRT in 15 patients and considered this technique as a simple and excellent alternative procedure for LV lead implantation with favorable pacing results. In another report, Hofmann et al.[4] used an Alexis® retractor and a camera port for LV lead implantation in a case with massive pleural adhesions for the first time in the literature.

In our case, we describe a new and slightly different method than VATS technique. We used a single-port and a retractor for all instruments. This approach is simpler, has better cosmetic results, and causes less pain due to reduction in the number of intercostal spaces and avoiding the use of a trocar in the procedure, which minimizes the risk of intercostal nerve injury. Our technique is similar to the method used by Hofmann et al.[4] However, we used single port for the instrumentation, camera, and chest tube insertion rather than opening an additional camera port.

In conclusion, left ventricular lead implantation via a single port is an excellent alternative both for open surgical approach and conventional video-assisted thoracoscopic surgery procedure. It is simpler and more tolerable with improved cosmetic outcomes than video-assisted thoracoscopic surgery procedure.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

References

1) Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J 2013;34:2281-329.

2) Jeong DS, Park PW, Lee YT, Park SJ, Kim JS, On YK. Thoracoscopic left ventricular lead implantation in cardiac resynchronization therapy. J Korean Med Sci 2012;27:1595-7.

3) Civelek A, Klövekorn WP. Cardiac resynchronization in patients with severe heart failure: is an alternative therapy? Turk Gogus Kalp Dama 2003;11:201-5.

4) Hofmann HS, Ried M, Sziklavari Z. Minimally invasive epicardial left ventricular lead placement in a case of massive pleural adhesion. J Cardiothorac Surg 2014;10;9:70.

5) Gabor S, Prenner G, Wasler A, Schweiger M, Tscheliessnigg KH, Smolle-Jüttner FM. A simplified technique for implantation of left ventricular epicardial leads for biventricular re-synchronization using videoassisted thoracoscopy (VATS). Eur J Cardiothorac Surg 2005;28:797-800.