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OBJECTIVE:
To study the feasibility, safety and efficacy of TEE guided intraoperative left ventricular (LV) lead placement via a video-assisted thoracoscopic surgery (VATS) approach in patients who are non-responders to conventional biventricular pacing (BIVP).
METHODS:
Eight patients underwent epicardial LV lead placement by VATS. 5/8 patients had prior chest surgery. For safety reasons the positioning was a modified far lateral supine exposure with 30° bed tilt, allowing for groin and sternal access if needed. To determine the optimal LV location for lead placement, the whole LV surface was divided arbitrarily into 9 segments. These segments were transpericardially paced using a hand held malleable pacing probe to identify the optimal site verified by TEE functional assessment. The pacing lead was screwed into position via a limited pericardiotomy. The leads were then tunneled subcutaneously to the device.
RESULTS:
The VATS approach was successful in all patients. BIVP was achieved in all patients and all reported symptomatic benefit with reduction in New York Heart Association class from III to I-II (p<0.03). Baseline mean QRS interval was 168ms (range 148-182). At 3 months follow up the mean QRS was 160ms (range 132-196). Satisfactory pacing thresholds and impedances were achieved intraoperatively and at subsequent follow-up. The mean follow-up was 338 days. The median length of hospital stay was 7 days (range 3-16) with chest tube removal between post-op days 2-5.
CONCLUSIONS:
In patients who are non responders to conventional BIV pacing, intraoperative LV lead placement using anatomical and functional characteristics via a VATS approach is effective in improving heart failure symptoms. This optimized LV lead placement is feasible and safe. Prior chest surgery is no longer an exclusion criterion for a VATS approach.