Cost-favorable Alternative To Wireless Cardiac Resynchronization: Super-responder Status With Posterolateral Minithoracotomy
Joseph M. Arcidi1, Tin C. Botzler1, Jeffrey S. Johnston2, Andrea M. Reed2, Sean E. Purtell2.
1Providence St. Joseph Heart Institute, Eureka, CA, USA, 2Providence St. Joseph Hospital, Eureka, CA, USA.
BACKGROUND: The importance of left ventricular (LV) lead position in obtaining a favorable response to cardiac resynchronization (CRT) has led to interest in wireless LV endocardial lead systems to overcome the limitations of transvenous coronary sinus LV lead insertion. We chose an alternative surgical approach to epicardial lead placement in a patient that facilitated cost-effective achievement of CRT super-responder [ejection fraction ≥ 50%] status.
METHODS: This 70yo woman with a nonischemic dilated cardiomyopathy, NYHA Class III function, left bundle branch block, and LV ejection fraction of 30% was referred for epicardial LV lead implantation following attempted coronary sinus insertion. We perceived, based on the CT scan, that a posterolateral approach would enable direct access to the basal obtuse margin (image: A, arrow). Full lateral decubitus positioning, with the left arm independently draped, provided entire left chest exposure. A 3-inch, sixth interspace posterolateral thoracotomy was used with a small wound protector; the pericardium posterior to the phrenic nerve was located directly below the incision. A unipolar, screw-in lead was attached without specialized instrumentation to basal mid-lateral obtuse margin myocardium, then tested (24.4 mV R-wave, 0.8 V threshold) and tunneled to the (upgraded) pulse generator pocket. Follow-up testing showed 90% LV pacing with a 0.5 V threshold.
RESULTS: The patient was ambulatory without pain at discharge to home, and she achieved a 10-fold increase in exercise duration in cardiac rehabilitation, which persists at 1 year. Four-month postoperative echocardiography showed a LV ejection fraction of 54% and decrease in end-diastolic dimension from 5.6 cm to 3.4 cm. V1 QRS morphology changed and duration decreased from 185 msec to 160 msec (image: B,C).
CONCLUSIONS: Non rib-spreading, single skin-prep posterolateral minithoracotomy in our patient a) permitted torque-free epicardial LV lead localization at the basal mid-lateral obtuse margin site deemed favorable in LV endocardial CRT pacing scenarios, and b) achieved a 24 percentage-point increase in LV ejection fraction and durable NYHA Class improvement at 1 year at a fraction of the cost of wireless LV endocardial systems.
LEGEND: A) Posterolateral minithoracotomy approach (arrow) to the base of the obtuse margin. V1-V3 ECG: B) preoperative, C) 1-year postoperative.
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