12. Cardiac Resynchronization Therapy: Surgical Approach

Background Biventricular (BiV) pacing is a proven advantageous adjuvant therapy for patients with ventricular dyssynchrony associated with congestive heart failure. Endocardial left ventricular lead placement does have several limitations: 1) anatomic variations of the coronary venous system, 2) late lead dislodgement, and 3) phrenic/diaphragmatic stimulation. Epicardial lead placement is often a ‘rescue’ procedure after failed coronary sinus implantation but offers some advantages related to safety and a shorter implant time. The aim the study is to describe two different minimally invasive surgical techniques for LV epicardial lead placement for resynchronization therapy of patients with chronic heart failure. Methods Between December 2002 and December 2004, 88 patients (pts) underwent minimally invasive left ventricular lead placement, Videoendoscopic assisted surgery was performed in patients 31, and Minithoracotomy in 57. Fifty pts. (56.8%) were males, mean age was 67 ±8.3 years (35-83), 44 (54.5%) had previous cardiac surgery, 58 (66%) had ischemic cardiomyopathy, 20 (22.7%) NYHA III-IV, 31 (35%) had more than 3+ mitral regurgitation and 46 (52.3%) had implantable cardioverter defibrillators. Results There were no deaths. The mean hospital length of stay was 4.5 ± 3.2 days. Postoperative complications included non-dialysis renal failure in 4 pts. (4.5%), atrial fibrillation in 10 (11.3%), non sustained ventricular tachycardia in 3 (3.4%) and decompensate heart failure in 2 (6.2%). Significant improvements were observed in postoperative parameters in comparison to the preoperative period (Table). Conclusions Minimally invasive LV epicardial lead placement are effective and safety techniques, with minimal morbidity, and can be helpful in the treatment of this complex disease. Prospective randomized studies between epicardial and endocardial lead placements should further define the role of these different techniques in the resynchronization therapy for heart failure. ![Graphic][1] [1]: /embed/graphic-1.gif