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Endoscopic Epicardial Lead Implantation as a Primary Alternative for Repeated Failure of Endovascular Insertion for Cardiac Pacing and Re-Synchronization Therapy.
Nachum Nesher, Yosef Paz.
Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

OBJECTIVE: Numerous anomalies or post-procedural stricture of the central venous system prevent the optimal endovascular implantation of left ventricle lead in more than 10% of patients indicated for either permanent pacing or cardiac resynchronization therapy.
The endovenous approach may be one of the reasons for the large number of the non-responders reported in the literature.
The purpose of our report is to analyse the thoracoscopic technique and the immediate postoperative results of the lesser invasive epicardial approach as the first alternative to the traditional failed endovascular lead insertion.
METHODS: From January 2008 to November 2012 nine epicardial leads were introduced thoracoscopicaly at our center. Patients were placed in a supine position and were ventilated using a double lumen endotracheal intubation. A five mm 30 degree lance thoracoscope was inserted into the fifth intercostal mid-axillary line. A second 10mm port was created in the seventh intercostal anterior axillary line. The pericardium was opened interiorly to the phrenic nerve. A screw-in pacing lead (Medtronic Model 5071 Pacing lead, Minneapolis, MN) was inserted into the apical portion of the left ventricle. A third 5 mm port was needed for suturing, when a non-screw pacing lead was used (first 5 cases). After the lead was placed and assessment made with pacing system analyzer for threshold less than 1 V, they were brought to the chest wall and tunneled to the pacemaker generator pocket. A size 10 Jackson Pratt drain was placed into the pocket. Another small flexible drain was left inside the pleural cavity for the next 24h.
RESULTS: there was no deaths or any major surgical complication among these patients. All patients responded to the epicardial lead implantation in terms of appropriate pacing and conductivity. No clinical failure was observed and none needed another attempt.
CONCLUSIONS: Thoracoscopic lead insertion is safe and easy to perform and should be offered as the first choice for failed endovascular implantation. Improving the cooperation between cardiologists and cardiothoracic surgeons will probably attenuate the non-responder rate.

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