Cardiovascular Journal of Africa: Vol 28 No 1 (January/February 2016)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 1, January/February 2017 AFRICA 19
Surgical placement of left ventricular lead for cardiac
resynchronisation therapy after failure of percutaneous
attempt
Mehmet Ezelsoy, Muhammed Bayram, Suleyman Yazici, Nuran Yazicioglu, Ertan Sagbas
Abstract
Objective: Cardiac resynchronisation therapy has been shown
to be an effective treatment to improve functional status and
prolong survival of patients in advanced chronic heart failure.
This study assessed the surgical outcomes of left anterior
mini-thoracotomy for the implantation of left ventricular
epicardial pacing leads in cardiac resynchronisation therapy.
Methods: Our study consisted of 30 consecutive patients
who underwent cardiac resynchronisation therapy with a
left thoracotomy between November 2010 and April 2012 in
our clinic. Postoperative follow up included the assessment
of New York Heart Association (NYHA) functional class,
electrocardiography and echocardiography.
Results: There were 22 male and eight female patients with a
mean age of 68 ± 5.04 years. All patients were in NYHA class
III or IV. Pre-procedure mean left ventricular ejection frac-
tion was 28.1 ± 4.5% and post-procedural ejection fraction
improved to 31.7 ± 5.1%. The pre-operative QRS duration
changed from 171.7 ± 10.8 to 156.2 ± 4.4 ms after the opera-
tion. Also there was a significant reduction in left ventricular
end-diastolic dimension from 6.98 ± 0.8 to 6.72 ± 0.8 mm (p
< 0 .05), but no change in left ventricular end-systolic dimen-
sion and severity of mitral regurgitation. All patients had
successful surgical left ventricular lead placement. There was
no procedure-related mortality. The mean follow-up time was
40.4 months.
Conclusion: Surgical epicardial left ventricular lead placement
procedure is a safe and effective technique in patients with a
failed percutaneous attempt.
Keywords: cardiac resynchronisation therapy, surgically placed
epicardial left ventricular lead, heart failure
Submitted 6/12/15, accepted 3/4/16
Cardiovasc J Afr 2017; 28: 19–22
DOI: 10.5830/CVJA-2016-046
Cardiac resynchronisation therapy (CRT) improves the symptoms
of congestive heart failure (CHF), increases exercise tolerance
and decreases rates of hospital readmission. Furthermore, CRT
improves ejection fraction and survival rate.1 Most of these data
have been derived in large trials using a transvenous approach,
placing the left ventricular lead via the coronary sinus (CS).
While this approach is least invasive, it can be challenging
due to restriction of the coronary sinus anatomy, epicardial scar,
and unintended stimulation of the left phrenic nerve.2 Due to
these restrictions, success rates of the percutaneous approach
are 75 to 93%.3 We aimed to evaluate the surgical outcomes
of left anterior mini-thoracotomy for the implantation of left
ventricular epicardial pacing leads for CRT after failure of a
percutaneous attempt.
Methods
The ethics committee of Istanbul Bilim University approved this
study, which consisted of 30 consecutive patients who underwent
surgical placement between November 2010 and April 2012 of
a left ventricular (LV) lead with a left thoracotomy after failure
of the percutaneous attempt. This study included patients with
New York Heart Association (NYHA) functional class III or IV
heart failure, ischaemic (25%) or non-ischaemic cardiomyopathy
(75%) with a left ventricular ejection fraction (LVEF) ≤ 35% and
QRS duration > 120 ms.
Pre- and postoperative follow up involved assessment
of NYHA functional class, electrocardiography (ECG),
determination of QRS duration, and echocardiographic data.
LVEF, left ventricular end-diastolic dimension (LVEDD) and
severity of mitral regurgitation (MR) data were collected to
analyse the effect of CRT via epicardial LV lead placement on
reverse ventricular remodelling. The procedures followed were in
accordance with institutional guidelines.
A mini-thoracotomy was performed under deep sedation
with no need for selective intubation. The patients were placed
in a 45° rotation to the right side. A 3- to 4-cm long left mini-
thoracotomy was performed through the fourth intercostal space
between the anterior and mid-axillary line. The pericardium
was opened longitudinally anterior to the phrenic nerve and
suspended with traction sutures to better expose the lateral wall.
Epicardial leads were implanted posterior to an obtuse marginal
branch, avoiding areas of scarred myocardium.
Once a site with satisfactory pacing threshold was identified
(impedance > 200 Ω and < 2 000 Ω, sensing > 5 mV and pacing
threshold measured at 0.5 ms < 2.0 V), the lead was sewn with 5/0
polypropylene sutures. The connector of the lead was tunnelled
submuscularly to the device pocket and the pacemaker. Patients
were generally extubated in the operating room and observed in
the cardiac surgery recovery unit.
Department of Cardiovascular Surgery, Bilim University,
Istanbul, Turkey
Mehmet Ezelsoy, MD,
Suleyman Yazici, MD
Ertan Sagbas, MD
Department of Cardiovascular Surgery, Mehmet Akif Ersoy
Hospital, Istanbul, Turkey
Muhammed Bayram, MD
Cardiology, Florence Nightingale Hospital, Istanbul, Turkey
Nuran Yazicioglu, MD