A Hybride Procedure Combining Mini-Thoracotomy with Interventional Endocardial Lead Implantation for Cardiac Resynchronization Therapy in Patients with Chronic Congestive Heart Failure: A Report of 4 Cases
Journal Title: Biomedical Journal of Scientific & Technical Research (BJSTR) - Year 2019, Vol 19, Issue 2
Abstract
We investigated the application and outcomes of a hybride procedure combining left ventricular epicardial lead implantation via mini-thoracotomy with interventional endocardial lead implantation for cardiac resynchronization in the treatment of chronic heart failure. Epicardial lead implantation was applied via a small left-sided chest incision through the fourth or fifth intercostal space in 4 patients with chronic heart failure who were not suitable for left ventricular endocardial lead implantation. The surgical technique of epicardial lead implantation and its short-term outcomes were analyzed. Epicardial lead implantation was successfully performed in all 4 patients, with significant postoperative improvements in hemodynamics, cardiac function and clinical symptoms. 4 Patients were discharged 8, 11, 4 and 7 days after surgery respectively and followed for 12 months. No lead breakage or wound infection were found on followup. The pacing threshold and lead impedance were normal. Phrenic nerve irritation was observed in one patient because the lead was placed lower than that of other three patients but improved obviously after lowering the threshold. No other complications were observed. In conclusion, trans-thoracic left ventricular epicardial lead implantation is a safe, feasible and effective method for cardiac resynchronization therapy. A hybrid procedure combining the interventional endocardial lead implantation with minithoracotomy may maximize CRT outcomes and can be widely applied.A 76-year-old female patient was admitted due to “repeated episodes of chest tightness and shortness of breath for more than 10 years and chest pain for 1 year, which had been aggravated for half a month.” The patient was diagnosed with dilated cardiomyopathy. Electrocardiography showed sinus rhythm, a QRS length of 170ms, complete left bundle branch block, PR interval of 150 ms, and P wave duration of 110 m s. Echocardiography showed that Left Ventricular End Diastolic Diameter (LVEDD) was 83mm, Left Ventricular End Systolic Diameter (LVES) was 70 mm, and Left Ventricular Ejection Fraction (LVEF) was 26%. The cardiothoracic ratio was 0.70. The clinical characteristics of the case were in accordance with class I indication of CRT. Angiography showed coronary sinus malformation, great cardiac vein and posterior vein of the left ventricle. Hence, transvenous implantation of the left ventricular lead was not possible, and we therefore performed epicardial left ventricular lead implantation via a small chest incision. The surgery was divided into two parts. First, right atrial and right ventricular lead implantation was carried out in a catheterization laboratory. The patient then underwent epicardial left ventricular lead implantation in the operating room. The patient was placed in the supine position and the left chest was elevated. An incision of about 5cm in length was made at the left anterolateral chest (Figure 1). Access to the chest was obtained through the fifth intercostal space. A longitudinal incision was made in the anterior pericardium to expose the heart. Two 6-0 prolene sutures were preset in the epicardium beneath the first diagonal branch of the left anterior descending artery to fix the epicardial lead in the avascular zone (Figure 2). The pacing parameters were measured. The left ventricular impedance was 783Ω, the threshold was 2.0mV, and the R-wave amplitude was 2.5mV. Then, a small incision was made in the corresponding part of the pericardium to allow removal of the epicardial lead line, which was then pulled through the upper intercostal space to the subcutaneous tunnel and brought into the pocket of the pacemaker. A fistula was made in the pericardium posterior to the left phrenic nerve for drainage. Intermittent suture of the pericardial incision was carried out. The pacing parameters were measured again. The left ventricular impedance was 783Ω, the threshold was 1.0V, and the R-wave amplitude was 2.5mV. Phrenic nerve irritation matching the higher threshold was observed once during the adjustment process. A drainage tube was placed through the left chest wall and the chest wound was closed.
Authors and Affiliations
Haiyan Xiang, Rifeng Gao, Juesheng Yang, Juxiang Li, Ji Li, Fei Lu, Yanhua Tang
Keywords
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- EP ID EP621712
- DOI 10.26717/BJSTR.2019.19.003289
- Views 164
- Downloads 0
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