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Neves Pereira MT, Tinoco M, Castro M, Pinheiro L, Cardoso F, Calvo L, Ribeiro S, Monteiro V, Sanfins V, Lourenço A. Assessing cardiac resynchronization therapy response in heart failure patients: a comparative analysis of efficacy and outcomes between transvenous and epicardial leads. Monaldi Arch Chest Dis 2024. [PMID: 38332712 DOI: 10.4081/monaldi.2024.2845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/23/2024] [Indexed: 02/10/2024] Open
Abstract
Cardiac resynchronization therapy (CRT) is an effective treatment for selected heart failure (HF) patients. Although transvenous implantation is the standard method, it is not feasible in some patients, so the epicardial lead emerges as an alternative. We aim to compare CRT response, procedure-related complications, and the occurrence of clinical outcomes between patients with transvenous and epicardial leads. In a single-center retrospective study, we enrolled consecutive HF patients submitted to CRT implantation with a defibrillator between 2013 and 2022. Clinical response was defined as an improvement of at least one of the New York Heart Association classes with no occurrence of cardiovascular death or HF hospitalization in the first year of follow-up. Echocardiographic response was attained with an increase in left ventricular ejection fraction 10% or a reduction of left ventricular end-diastolic volume >15% at 6-12 months after CRT implantation. Major adverse cardiovascular events (MACE) (cardiovascular mortality and HF hospitalization) and all-cause mortality were evaluated. From a total of 149 patients, 38% (n=57) received an epicardial lead. Clinical (63% versus 60%, p=0.679) and echocardiographic (63% versus 60%, p=0.679) responses were similar between the transvenous and epicardial groups. Patients in the transvenous group had a shorter hospital stay (2 versus 7 days, p<0.001). Procedure-related complications were comparable between groups (24% versus 28%, p=0.572), but left ventricular lead-related complications were more frequent in the transvenous group (14% versus 2%). During a median follow-up of 4.7 years, the rate of MACE was 30% (n=44), with no differences in both groups (p=0.591), neither regarding HF hospitalization (p=0.917) nor cardiovascular mortality (p=0.060). Nevertheless, the epicardial group had a higher rate of all-cause mortality (35% versus 20%, p=0.005), the majority occurring during long-term follow-up (>12 months), with no deaths in the postoperative period. Considering the comparable rates of CRT response, procedure-related complications, and MACE between groups, we conclude that epicardial lead is a feasible alternative for CRT when transvenous lead implantation is not possible. The occurrence of a higher number of all-cause deaths in epicardial patients in the long-term follow-up was mainly due to infectious complications (unrelated to the lead) and the progression of oncological/chronic diseases.
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Affiliation(s)
| | | | | | | | | | - Lucy Calvo
- Senhora da Oliveira Hospital, Guimarães.
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2
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Marini M, Pannone L, Branzoli S, Quintarelli S, Coser A, Guarracini F, Bonmassari R, La Meir M, de Asmundis C. Video-assisted thoracoscopic epicardial pacing: A contemporary overview. Pacing Clin Electrophysiol 2023; 46:1215-1221. [PMID: 37676730 DOI: 10.1111/pace.14815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/22/2023] [Indexed: 09/09/2023]
Abstract
Video-assisted thoracoscopic surgery (VATS) has revolutionized the approach and management of pulmonary and cardiac diseases, and its applications have significantly expanded in the last two decades. Beyond its established role in thoracic procedures, VATS has also emerged as a valuable technique for various electrophysiological procedures, including pacemaker implantations, ablation procedures, and left atrial appendage exclusion. This paper presents a thorough review of the existing literature on pacing procedures performed using a VATS approach. By analyzing and synthesizing the available studies, we aim to provide an in-depth understanding of the current knowledge and advancements in VATS-based pacing procedures. A key focus of this review is the detailed description of implantation techniques via a VATS approach.
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Affiliation(s)
- Massimiliano Marini
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
- Heart Rhythm Management Centre, Postgraduate program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Stefano Branzoli
- Department of Cardiac Surgery, S. Chiara Hospital, Trento, Italy
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - Alessio Coser
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
| | | | | | - Mark La Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
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3
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de Maat GE, Mulder BA, Van de Lande ME, Rama RS, Rienstra M, Mariani MA, Maass AH, Klinkenberg TJ. Long-Term Performance of Epicardial versus Transvenous Left Ventricular Leads for Cardiac Resynchronization Therapy. J Clin Med 2023; 12:5766. [PMID: 37762709 PMCID: PMC10531585 DOI: 10.3390/jcm12185766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/20/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023] Open
Abstract
Aims: to study the technical performance of epicardial left ventricular (LV) leads placed via video assisted thoracic surgery (VATS), compared to transvenously placed leads for cardiac resynchronization therapy (CRT). Methods: From 2001 until 2013, a total of 644 lead placement procedures were performed for CRT. In the case of unsuccessful transvenous LV lead placement, the patient received an epicardial LV lead. Study groups consist of 578 patients with a transvenous LV lead and 66 with an epicardial LV lead. The primary endpoint was LV-lead failure necessitating a replacement or deactivation. The secondary endpoint was energy consumption. Results: The mean follow up was 5.9 years (epicardial: 5.5 ± 3.1, transvenous: 5.9 ± 3.5). Transvenous leads failed significantly more frequently than epicardial leads with a total of 66 (11%) in the transvenous leads group vs. 2 (3%) in the epicardial lead group (p = 0.037). Lead energy consumption was not significantly different between groups. Conclusions: Epicardial lead placement is feasible, safe and shows excellent long-term performance compared to transvenous leads. Epicardial lead placement should be considered when primary transvenous lead placement fails or as a primary lead placement strategy in challenging cases.
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Affiliation(s)
- Gijs E. de Maat
- Department of Cardio-Thoracic Surgery, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (G.E.d.M.); (M.A.M.); (T.J.K.)
| | - Bart A. Mulder
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (B.A.M.); (M.E.V.d.L.); (R.S.R.); (M.R.)
| | - Martijn E. Van de Lande
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (B.A.M.); (M.E.V.d.L.); (R.S.R.); (M.R.)
| | - Rajiv S. Rama
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (B.A.M.); (M.E.V.d.L.); (R.S.R.); (M.R.)
| | - Michiel Rienstra
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (B.A.M.); (M.E.V.d.L.); (R.S.R.); (M.R.)
| | - Massimo A. Mariani
- Department of Cardio-Thoracic Surgery, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (G.E.d.M.); (M.A.M.); (T.J.K.)
| | - Alexander H. Maass
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (B.A.M.); (M.E.V.d.L.); (R.S.R.); (M.R.)
| | - Theo J. Klinkenberg
- Department of Cardio-Thoracic Surgery, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands; (G.E.d.M.); (M.A.M.); (T.J.K.)
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4
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Cioffi GM, Gasperetti A, Tersalvi G, Schiavone M, Compagnucci P, Sozzi FB, Casella M, Guerra F, Dello Russo A, Forleo GB. Etiology and device therapy in complete atrioventricular block in pediatric and young adult population: Contemporary review and new perspectives. J Cardiovasc Electrophysiol 2021; 32:3082-3094. [PMID: 34570400 DOI: 10.1111/jce.15255] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 08/24/2021] [Accepted: 09/11/2021] [Indexed: 11/30/2022]
Abstract
Complete atrioventricular block (CAVB) is a total dissociation between the atrial and ventricular activity, in the absence of atrioventricular conduction. Several diseases may result in CAVB in the pediatric and young-adult population. Permanent right ventricular (RV) pacing is required in permanent CAVB, when the cause is neither transient nor reversible. Continuous RV apical pacing has been associated with unfavorable outcomes in several studies due to the associated ventricular dyssynchrony. This study aims to summarize the current literature regarding CAVB in the pediatric and young adult population and to explore future treatment perspectives.
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Affiliation(s)
- Giacomo M Cioffi
- Division of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Alessio Gasperetti
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy.,Cardiology and Arrhythmology Clinic, Department of Biomedical Sciences and Public Health, University Hospital "Umberto I-Lancisi-Salesi", Marche Polytechnic University, Ancona, Italy.,Department of Cardiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Gregorio Tersalvi
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.,Department of Internal Medicine, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - Marco Schiavone
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Department of Biomedical Sciences and Public Health, University Hospital "Umberto I-Lancisi-Salesi", Marche Polytechnic University, Ancona, Italy
| | - Fabiola B Sozzi
- Department of Cardiology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Department of Clinical, Special and Dental Sciences, University Hospital "Umberto I-Lancisi-Salesi", Marche Polytechnic University, Ancona, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Department of Biomedical Sciences and Public Health, University Hospital "Umberto I-Lancisi-Salesi", Marche Polytechnic University, Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Department of Biomedical Sciences and Public Health, University Hospital "Umberto I-Lancisi-Salesi", Marche Polytechnic University, Ancona, Italy
| | - Giovanni Battista Forleo
- Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy
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5
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Sinno MC, Carrigan T, Hays JC. Caudocranial transseptal approach for placement of endocardial left ventricular leads. J Cardiovasc Electrophysiol 2020; 31:2216-2221. [PMID: 32608150 DOI: 10.1111/jce.14644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/02/2020] [Accepted: 06/21/2020] [Indexed: 11/30/2022]
Abstract
Cardiac resynchronization therapy (CRT) is associated with improvement in the quality of life, hospitalization rates, and mortality in patients with left ventricular dysfunction and evidence of the right ventricle-left ventricle (RV-LV) desynchrony. Implant failure rates and patient outcomes have improved with the advent of quadripolar leads, yet alternatives to traditional coronary sinus (CS) LV lead placement is sought for in a subset of advanced heart failure patients with difficult CS anatomy, phrenic nerve stimulation or in nonresponders. Endocardial left ventricular pacing (EnLVP) in chronically anticoagulated patients has been reported as an alternative using different approaches, techniques, and tools with acceptable short and long term adverse events. We present a case of successful EnLVP achieved for CRT using standard techniques and commonly available tools in a patient on chronic direct oral anticoagulation with recurrent heart failure admissions who failed traditional epicardial LV pacing.
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Affiliation(s)
- Mohamad C Sinno
- Department of Cardiac Electrophysiology, Heart and Vascular Institute, St Elizabeth Healthcare, Edgewood, Kentucky
| | - Thomas Carrigan
- Department of Cardiac Electrophysiology, Heart and Vascular Institute, St Elizabeth Healthcare, Edgewood, Kentucky
| | - J Christian Hays
- Department of Cardiac Electrophysiology, Heart and Vascular Institute, St Elizabeth Healthcare, Edgewood, Kentucky
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6
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Marini M, Branzoli S, Moggio P, Martin M, Belotti G, Molon G, Guarracini F, Coser A, Quintarelli S, Pederzolli C, Graffigna A, Penzo D, Valsecchi S, Bottoli MC, Pepi P, Bonmassari R, Droghetti A. Epicardial left ventricular lead implantation in cardiac resynchronization therapy patients via a video-assisted thoracoscopic technique: Long-term outcome. Clin Cardiol 2019; 43:284-290. [PMID: 31837030 PMCID: PMC7068064 DOI: 10.1002/clc.23300] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 11/10/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Epicardial placement of the left ventricular (LV) lead via a video-assisted thoracoscopic (VAT) approach is an alternative to the standard transvenous technique. HYPOTHESIS Long-term safety and efficacy of VAT and transvenous LV lead implantation are comparable. To test it, we reviewed our experience and we compared the outcomes of patients who underwent implantation with the two techniques. METHODS The VAT procedure is performed under general anesthesia, with oro-tracheal intubation and right-sided ventilation, and requires two 5 mm and one 15 mm thoracoscopic ports. After pericardiotomy at the spot of the epicardial target area, pacing measurements are taken and a spiral screw electrode is anchored at the final pacing site. The electrode is then tunneled to the pectoral pocket and connected to the device. RESULTS 105 patients were referred to our center for epicardial LV lead implantation. After pre-operative assessment, 5 patients were excluded because of concomitant conditions precluding surgery. The remaining 100 underwent the procedure. LV lead implantation was successful in all patients (median pacing threshold 0.8 ± 0.5 V, no phrenic nerve stimulation) and cardiac resynchronization therapy was established in all but one patient. The median procedure time was 75 min. During a median follow-up of 24 months, there were no differences in terms of death, cardiovascular hospitalizations or device-related complications vs the group of 100 patients who had undergone transvenous implantation. Patients of both groups displayed similar improvements in terms of ventricular reverse remodeling and functional status. CONCLUSIONS Our VAT approach proved safe and effective, and is a viable alternative in the case of failed transvenous LV implantation.
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Affiliation(s)
| | - Stefano Branzoli
- Department of Cardiac Surgery, S. Chiara Hospital, Trento, Italy
| | - Paolo Moggio
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
| | - Marta Martin
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
| | | | - Giulio Molon
- Department of Cardiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | | | - Alessio Coser
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
| | | | - Carlo Pederzolli
- Department of Cardiac Surgery, S. Chiara Hospital, Trento, Italy
| | - Angelo Graffigna
- Department of Cardiac Surgery, S. Chiara Hospital, Trento, Italy
| | - Daniele Penzo
- Department of Anesthesiology, S. Chiara Hospital, Trento, Italy
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7
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Mattson AR, Soto MJ, Iaizzo PA. The quantitative assessment of epicardial fat distribution on human hearts: Implications for epicardial electrophysiology. Clin Anat 2018; 31:661-666. [PMID: 29700862 DOI: 10.1002/ca.23194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 11/12/2022]
Abstract
Epicardial electrophysiological procedures rely on dependable interfacing with the myocardial tissue. For example, epicardial pacing systems must generate sustainable chronic pacing capture, while epicardial ablations must effectively deliver energy to the target hyper-excitable myocytes. The human heart has a significant adipose layer which may impede epicardial procedures. The objective of this study was to quantitatively assess the relative location of epicardial adipose on the human heart, to define locations where epicardial therapies might be performed successfully. We studied perfusion-fixed human hearts (n = 105) in multiple isolated planes including: left ventricular margin, diaphragmatic surface, and anterior right ventricle. Relative adipose distribution was quantitatively assessed via planar images, using a custom-generated image analysis algorithm. In these specimens, 76.7 ± 13.8% of the left ventricular margin, 72.7 ± 11.3% of the diaphragmatic surface, and 92.1 ± 8.7% of the anterior right margin were covered with superficial epicardial adipose layers. Percent adipose coverage significantly increased with age (P < 0.001) and history of coronary artery disease (P < 0.05). No significant relationships were identified between relative percent adipose coverage and gender, body weight or height, BMI, history of hypertension, and/or history of congestive heart failure. Additionally, we describe two-dimensional probability distributions of epicardial adipose coverage for each of the three analysis planes. In this study, we detail the quantitative assessment and probabilistic mapping of the distribution of superficial epicardial adipose on the adult human heart. These findings have implications relative to performing epicardial procedures and/or designing procedures or tools to successfully perform such treatments. Clin. Anat. 31:661-666, 2018. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Alexander R Mattson
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota.,Medtronic, Mounds View, Minnesota
| | - Mario J Soto
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, 55455
| | - Paul A Iaizzo
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, Minnesota.,Department of Surgery, University of Minnesota, Minneapolis, Minnesota, 55455
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8
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Fedorco M, Bulava A, Šantavý P, Mokráček A, Lonský V, Dušek L, Táborský M. Middle-term stability of epicardial left ventricular electrodes for cardiac resynchronization therapy. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2016.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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9
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Caliskan E, Fischer F, Schoenrath F, Emmert MY, Maisano F, Falk V, Starck CT, Holubec T. Epicardial left ventricular leads via minimally invasive technique: a role of steroid eluting leads. J Cardiothorac Surg 2017; 12:95. [PMID: 29117867 PMCID: PMC5678761 DOI: 10.1186/s13019-017-0659-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 11/01/2017] [Indexed: 11/30/2022] Open
Abstract
Background We retrospectively assessed two types of sutureless screw-in left ventricular (LV) leads (steroid eluting vs. non-steroid eluting) in cardiac resynchronization therapy (CRT) implantation with regards to their electrical performance. Methods Between March 2008 and May 2014 an epicardial LV lead was implanted in 32 patients after failed transvenous LV lead placement using a left-sided lateral minithoracotomy or video-assisted thoracoscopy (mean age 64 ± 9 years). Patients were divided into two groups according to the type of implanted lead. Steroid eluting (SE) group: 21 patients (Myodex™ 1084 T; St. Jude Medical) and non-steroid eluting (NSE) group: 11 patients (MyoPore® 511,212; Greatbatch Medical). Results All epicardial leads could be placed successfully, without any intraoperative complications or mortality. With regard to the implanted lead following results were observed: sensing (mV): SE 8.8 ± 6.1 vs. NSE 10.1 ± 5.3 (p = 0.380); pacing threshold (V@0.5 ms): SE 1.0 ± 0.5 vs. NSE 0.9 ± 0.5 (p = 0.668); impedance (ohms): SE 687 ± 236 vs. NSE 790 ± 331 (p = 0.162). At the follow-up (2.6 ± 1.9 years) the following results were seen: sensing (mV): SE 8.7 ± 5.0 vs. NSE 11.2 ± 6.6 (p = 0.241), pacing threshold (V@0.5 ms): SE 1.4 ± 0.5 vs. NSE 1.0 ± 0.3 (p = 0.035), impedance (ohms): SE 381 ± 95 vs. NSE 434 ± 88 (p = 0.129). Conclusions Based on the results no strong differences have been found between the both types of epicardial LV leads (steroid eluting vs. non-steroid eluting) in CRT implantation in short- and midterm.
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Affiliation(s)
- Etem Caliskan
- Clinic for Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Florian Fischer
- Clinic for Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
| | - Maximilian Y Emmert
- Clinic for Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Francesco Maisano
- Clinic for Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
| | - Christoph T Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
| | - Tomas Holubec
- Clinic for Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland. .,Department of Cardiac Surgery, Kerckhoff Heart and Lung Center, 61231, Bad Nauheim, Germany.
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10
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Providencia R, Barra S, Papageorgiou N, Ioannou A, Rogers D, Wongwarawipat T, Falconer D, Duehmke R, Colicchia M, Babu G, Segal OR, Sporton S, Dhinoja M, Ahsan S, Ezzat V, Rowland E, Lowe M, Lambiase PD, Agarwal S, Chow AW. Dual-site right ventricular pacing in patients undergoing cardiac resynchronization therapy: Results of a multicenter propensity-matched analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1113-1120. [PMID: 28734025 DOI: 10.1111/pace.13145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 05/26/2017] [Accepted: 06/13/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Dual-site right ventricular pacing (Dual RV) has been proposed as an alternative for patients with heart failure undergoing cardiac resynchronization therapy (CRT) with a failure to deliver a coronary sinus (CS) lead. Only short-term hemodynamic and echocardiographic results of Dual RV are available. We aimed to assess the long-term results of Dual RV and its impact on survival. METHODS Multicenter retrospective assessment of all CRT implants during a 12-year period. Patients with failed CS lead implantation, treated with Dual RV, were followed and assessed for the primary endpoint of all-cause mortality and/or heart transplant. A control group was obtained from contemporary patients using propensity matching for all available baseline variables. RESULTS Ninety-three patients were implanted with Dual RV devices and compared with 93 matched controls. During a median of 1,273 days (interquartile range 557-2,218), intention-to-treat analysis showed that all-cause mortality and/or heart transplant was higher in the Dual RV group (adjusted hazard ratio [HR] = 1.66, 95% confidence interval [CI] 1.12-2.47, P = 0.012). As-treated analysis yielded similar results (HR = 1.97, 95% CI 1.31-2.96, P = 0.001). Cardiac device-related infections occurred seven times more frequently in the Dual RV site group (HR = 7.60, 95% CI 1.51-38.33, P = 0.014). Among Dual RV nonresponders, four had their apical leads switched off, five required an epicardial LV lead insertion, a transseptal LV lead was implanted in two, and in nine patients, after reviewing the CS venogram, a new CS lead insertion was successfully attempted. CONCLUSION Dual RV pacing is associated with worse clinical outcomes and higher complication rates than conventional CRT.
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Affiliation(s)
| | - Sergio Barra
- Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Adam Ioannou
- The Heart Hospital, University College of London Hospitals NHS Trust, London, UK
| | - Dominic Rogers
- The Heart Hospital, University College of London Hospitals NHS Trust, London, UK
| | | | - Debbie Falconer
- The Heart Hospital, University College of London Hospitals NHS Trust, London, UK
| | | | | | - Girish Babu
- The Heart Hospital, University College of London Hospitals NHS Trust, London, UK
| | | | - Simon Sporton
- Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Mehul Dhinoja
- Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Syed Ahsan
- Barts Heart Centre, Barts Health NHS Trust, London, UK
| | | | | | - Martin Lowe
- Barts Heart Centre, Barts Health NHS Trust, London, UK
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11
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van Dijk VF, Fanggiday J, Balt JC, Wijffels MC, Daeter EJ, Kelder JC, Boersma LV. Effects of epicardial versus transvenous left ventricular lead placement on left ventricular function and cardiac perfusion in cardiac resynchronization therapy: A randomized clinical trial. J Cardiovasc Electrophysiol 2017; 28:917-923. [DOI: 10.1111/jce.13242] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/13/2017] [Accepted: 04/20/2017] [Indexed: 11/30/2022]
Affiliation(s)
| | - Jim Fanggiday
- Department of Nuclear medicine; St Antonius Hospital
| | | | | | - Edgar J. Daeter
- Department of Cardiothoracic surgery; St Antonius Hospital; Koekoekslaan 1 3435 CM Nieuwegein The Netherlands
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12
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Ezelsoy M, Bayram M, Yazici S, Yazicioglu N, Sagbas E. Surgical placement of left ventricular lead for cardiac resynchronisation therapy after failure of percutaneous attempt. Cardiovasc J Afr 2017; 28:19-22. [PMID: 28262910 PMCID: PMC5423426 DOI: 10.5830/cvja-2016-046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 04/03/2016] [Indexed: 01/04/2023] Open
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 fraction 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 operation. 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 dimension 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.
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Affiliation(s)
- Mehmet Ezelsoy
- Department of Cardiovascular Surgery, Bilim University, Istanbul, Turkey.
| | - Muhammed Bayram
- Department of Cardiovascular Surgery, Mehmet Akif Ersoy Hospital, Istanbul, Turkey
| | - Suleyman Yazici
- Department of Cardiovascular Surgery, Bilim University, Istanbul, Turkey
| | | | - Ertan Sagbas
- Department of Cardiovascular Surgery, Bilim University, Istanbul, Turkey
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McALOON CJ, Anderson BM, Dimitri W, Panting J, Yusuf S, Bhudia SK, Osman F. Long-Term Follow-Up of Isolated Epicardial Left Ventricular Lead Implant Using a Minithoracotomy Approach for Cardiac Resynchronization Therapy. Pacing Clin Electrophysiol 2016; 39:1052-1060. [PMID: 27501471 DOI: 10.1111/pace.12932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 07/20/2016] [Accepted: 07/31/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Transvenous left ventricular (LV) lead placement for cardiac resynchronization therapy is unsuccessful in 5-10% of reported cases. These patients may benefit from isolated surgical placement of an epicardial LV lead via minithoracotomy approach. AIM To evaluate the success of this approach at long-term follow-up. METHODS Retrospective evaluation of all consecutive patients undergoing isolated epicardial LV lead placement after failed transvenous attempt over a 6-year period. Data collected on baseline parameters, procedural details, and outcome at follow-up (hospital stay, complications, mortality, and clinical response). RESULTS Forty-two patients underwent epicardial lead implant. Five died within 1 year (11.9%): two (4.8%) died within 30-days post op (one from intraoperative hemorrhage, the other from multiple organ failure); 39 (95.1%) were admitted to the high dependency unit and transferred to the ward <24 hours. Median hospital stay was 3.4 ± 1.9 days. The overall complication rate was 17.5% (n = 7): 15.0% (n = 6) short term and 2.5% (n = 1) long term; these included three (7.5%) LV noncapture events all treated with reprogramming. There were two (5.0%) wound infections requiring oral antibiotics and two (5.0%) device infections requiring intravenous antibiotics (one had device resiting, the other developed septic shock requiring intensive care admission). Assessment of clinical response was possible in 34 (81.0%) at follow-up: 21 (61.8%) were responders and 13 (28.2%) nonresponders with no significant differences between these groups; no clinical predictors of response were identified. CONCLUSION Isolated epicardial LV lead implant using minithoracotomy is relatively safe and effective at successful LV pacing. Response rate and postoperative recovery at long-term follow-up are reasonable in these high-risk patients.
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Affiliation(s)
| | | | - Wadih Dimitri
- Department of Cardiology, University Hospital Coventry, Coventry, UK
| | - Jonathan Panting
- Department of Cardiology, Good Hope Hospital, Heart of England NHS Trust, Birmingham, UK
| | - Shamil Yusuf
- Department of Cardiology, Good Hope Hospital, Heart of England NHS Trust, Birmingham, UK
| | - Sunil K Bhudia
- Department of Cardiology, University Hospital Coventry, Coventry, UK
| | - Faizel Osman
- Department of Cardiology, University Hospital Coventry, Coventry, UK.
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Amraoui S, Labrousse L, Sohal M, Jansens JL, Berte B, Derval N, Denis A, Ploux S, Haissaguerre M, Jais P, Bordachar P, Ritter P. Alternative to left ventricular lead implantation through the coronary sinus: 1-year experience with a minimally invasive and robotically guided approach. Europace 2016; 19:88-95. [PMID: 26811434 DOI: 10.1093/europace/euv430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/10/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS Left ventricular (LV) lead implantation through the coronary sinus (CS) can be limited and sometimes not possible-alternative approaches are needed. Minimally invasive, robotically guided LV lead implantation has major advantages, but there are little published data about the short- and long-term follow-ups, in terms of feasibility, safety, electrical performance, and impact on clinical outcome. METHODS AND RESULTS A total of 21 heart failure patients underwent robotically guided LV lead implantation using the Da Vinci Robotic System. Indications were failed implant with conventional approach through the CS (n = 16) and non-response to conventional cardiac resynchronization therapy (n = 5). During the procedure, the entire LV free wall was exposed through 3 transthoracic ports (10 mm diameter each) allowing ample choice of stimulation site and the ability to implant 2 LV leads via a Y connector. Patients were prospectively followed up for 1 year. The two LV leads were successfully implanted in all patients. No peri-procedural complications were observed. After a mean stay in the intensive care unit of 1.2 ± 4 days, the 21 patients were hospitalized in the EP department for 6.7 ± 2.9 days. Acute LV thresholds were excellent (1.0 V ± 0.6/0.4 ms) and stayed stable at 1-year follow-up (1.5 V ± 0.6/0.4 ms, P = 0.21). Four patients demonstrated an increased threshold (>2 V/0.4 ms). There was no phrenic nerve stimulation. After 12 months, in the failed implant group, 69% of the patients were echocardiographic and clinical responders. CONCLUSION The robotic approach was feasible, safe, and minimally invasive. Accordingly, robotically guided LV lead implantation seems to offer a new alternative when conventional approaches are not suitable.
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Affiliation(s)
- Sana Amraoui
- Université de Bordeaux, Hôpital Haut-Lévêque, LIRYC, Bordeaux-Pessac 33604, France
| | - Louis Labrousse
- Université de Bordeaux, Hôpital Haut-Lévêque, LIRYC, Bordeaux-Pessac 33604, France
| | - Manav Sohal
- Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Jean-Luc Jansens
- Free University of Brussels (ULB), Hôpital Erasme, Brussel, Belgium
| | - Benjamin Berte
- Université de Bordeaux, Hôpital Haut-Lévêque, LIRYC, Bordeaux-Pessac 33604, France
| | - Nicolas Derval
- Université de Bordeaux, Hôpital Haut-Lévêque, LIRYC, Bordeaux-Pessac 33604, France
| | - Arnaud Denis
- Université de Bordeaux, Hôpital Haut-Lévêque, LIRYC, Bordeaux-Pessac 33604, France
| | - Sylvain Ploux
- Université de Bordeaux, Hôpital Haut-Lévêque, LIRYC, Bordeaux-Pessac 33604, France
| | - Michel Haissaguerre
- Université de Bordeaux, Hôpital Haut-Lévêque, LIRYC, Bordeaux-Pessac 33604, France
| | - Pierre Jais
- Université de Bordeaux, Hôpital Haut-Lévêque, LIRYC, Bordeaux-Pessac 33604, France
| | - Pierre Bordachar
- Université de Bordeaux, Hôpital Haut-Lévêque, LIRYC, Bordeaux-Pessac 33604, France
| | - Philippe Ritter
- Université de Bordeaux, Hôpital Haut-Lévêque, LIRYC, Bordeaux-Pessac 33604, France
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15
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Zhao ZQ, Liu T, Zhu XT, Cui L, Fan C, Zhang XW, Li GP. Epicardial or transvenous leads: Controversial for the placement in implantation of cardiac resynchronization therapy. Int J Cardiol 2016; 202:834-5. [PMID: 26476042 DOI: 10.1016/j.ijcard.2015.10.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 10/04/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Zhi-Qiang Zhao
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, People's Republic of China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, People's Republic of China
| | - Xiao-Tong Zhu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, People's Republic of China
| | - Li Cui
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, People's Republic of China
| | - Chong Fan
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, People's Republic of China
| | - Xiao-Wei Zhang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, People's Republic of China
| | - Guang-Ping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, People's Republic of China.
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CHEN LU, FU HAIXIA, PRETORIUS VICTORG, YANG DACHUN, WISTE HEATHERJ, YUAN HONGTAO, FELD GREGORYK, CHA YONGMEI, BIRGERSDOTTER-GREEN ULRIKAM. Clinical Outcomes of Cardiac Resynchronization with Epicardial Left Ventricular Lead. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1201-9. [DOI: 10.1111/pace.12687] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/26/2015] [Accepted: 07/05/2015] [Indexed: 11/30/2022]
Affiliation(s)
- LU CHEN
- Division of Cardiology, Department of Medicine; University of California; San Diego California
| | - HAIXIA FU
- Department of Cardiovascular Diseases; Henan Provincial People's Hospital, Zhengzhou University; Henan China
- Department of Cardiovascular Diseases; Mayo Clinics; Rochester Minnesota
| | - VICTOR G. PRETORIUS
- Department of Surgery, Division of Cardiothoracic Surgery; University of California; San Diego California
| | - DACHUN YANG
- Department of Cardiovascular Diseases; Mayo Clinics; Rochester Minnesota
| | - HEATHER J. WISTE
- Department of Health Science Research; Mayo Clinics; Rochester Minnesota
| | - HONGTAO YUAN
- Department of Cardiovascular Diseases; Mayo Clinics; Rochester Minnesota
| | - GREGORY K. FELD
- Division of Cardiology, Department of Medicine; University of California; San Diego California
| | - YONG-MEI CHA
- Department of Cardiovascular Diseases; Mayo Clinics; Rochester Minnesota
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Domenichini G, Diab I, Campbell NG, Dhinoja M, Hunter RJ, Sporton S, Earley MJ, Schilling RJ. A highly effective technique for transseptal endocardial left ventricular lead placement for delivery of cardiac resynchronization therapy. Heart Rhythm 2015; 12:943-9. [DOI: 10.1016/j.hrthm.2015.01.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Indexed: 11/24/2022]
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18
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Martens P, Verbrugge FH, Mullens W. Optimizing CRT - Do We Need More Leads and Delivery Methods. J Atr Fibrillation 2015; 7:1202. [PMID: 27957161 DOI: 10.4022/jafib.1202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 04/23/2015] [Accepted: 04/24/2015] [Indexed: 11/10/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an established therapeutic option in symptomatic heart failure with reduced ejection fraction and evidence of left ventricular (LV) conduction delay (QRS width ≥120 ms), especially when typical left bundle branch block is present. The rationale behind CRT is restoration of aberrant LV electrical activation. As there is considerable heterogeneity of the LV electrical activation pattern among CRT candidates, an individualized approach with targeting of the LV lead in the region of latest electrical activation while avoiding scar tissue may enhance CRT response. Echocardiography, electro anatomic mapping, and cardiac magnetic resonance imaging with late gadolinium enhancement are helpful to guide such targeted LV lead placement. However, an important limitation remains the anatomy of the coronary sinus, which often does not allow concordant LV lead placement in the optimal region. Epicardial LV lead placement through minimal invasive surgery or endocardial LV lead placement through transseptal punction may overcome this limitation, obviously with an increased complication risk. Furthermore, recent pacing algorithms suggest superiority of LV-only versus biventricular pacing in patients with preserved atrio ventricular (AV) conduction and a typical LBBB pattern. Finally, pacing from only one LV site might not overcome the wide electrical dispersion often seen in patients with LV conduction delays. Therefore, multisite pacing has gained significant interest to improve CRT response. The use of multiple LV leads may potentially lead to more favorable reverse remodeling, improved functional capacity and quality of life in CRT candidates, but adverse events and a shorter battery span are more frequent because of the extra lead. The use of one multipolar LV lead increases the number of pacing configurations within the same coronary sinus side branch (within small distances from each other) without the use of an additional lead. Small observational studies suggest that more effective resynchronization can be achieved with this approach. Finally, there are many reasons for non effective CRT delivery in carefully selected patients with an adequately implanted device. Multidisciplinary, post implantation care inside a dedicated CRT clinic ensures optimal CRT delivery, improves response rate and should be considered standard of care.
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Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Frederik Hendrik Verbrugge
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
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19
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Buiten MS, van der Heijden AC, Klautz RJ, Schalij MJ, van Erven L. Epicardial leads in adult cardiac resynchronization therapy recipients: A study on lead performance, durability, and safety. Heart Rhythm 2015; 12:533-539. [DOI: 10.1016/j.hrthm.2014.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Indexed: 01/17/2023]
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20
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MIHALCZ ATTILA, KASSAI IMRE, GELLER LASZLO, SZILI-TÖRÖK TAMAS. Alternative Techniques for Left Ventricular Pacing in Cardiac Resynchronization Therapy. Pacing Clin Electrophysiol 2013; 37:255-61. [DOI: 10.1111/pace.12320] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 09/26/2013] [Accepted: 10/13/2013] [Indexed: 11/30/2022]
Affiliation(s)
| | - IMRE KASSAI
- Hungarian National Institute of Cardiology; Budapest Hungary
| | - LASZLO GELLER
- Heart Center; Semmelweis University; Budapest Hungary
| | - TAMAS SZILI-TÖRÖK
- Department of Clinical Cardiac Electrophysiology; Thorax Centre; Rotterdam the Netherlands
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21
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Shan L, Buratto E, Conaglen P, Davis P, Yii M, Nixon I, Newcomb A. Prophylactic epicardial left ventricular lead implantation for biventricular pacing during operations. Ann Thorac Surg 2013; 97:603-8. [PMID: 24206965 DOI: 10.1016/j.athoracsur.2013.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 08/30/2013] [Accepted: 09/09/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Surgical epicardial left ventricular (LV) lead implantation for biventricular pacing has advantages over the transvenous approach in cardiac surgical patients. We investigated the benefit of concomitant prophylactic LV lead implantation during open heart operations and subsequent lead performance after patients with impaired LV function receive a biventricular device. METHODS Retrospective data of 4,844 patients undergoing cardiac operations through a sternotomy between January 2001 and December 2011 were analyzed. Of these, 380 patients (7.8%) had severe impairment of LV function (contrast left ventriculogram showing grade 4 estimated ejection fraction or echocardiogram showing LV ejection fraction<0.30). LV lead implantation was performed in patients in whom recovery of LV function was unlikely. Lead performance data were collected at follow-up. RESULTS LV lead implantation occurred in 95 patients (25%), and 29 (30.5%) subsequently received a biventricular device. Of patients with impaired LV function, more patients with prophylactic LV leads underwent biventricular implant than those without LV leads (30.5% vs 1.1%, p<0.0001). The median interval from LV lead implantation to connection to a biventricular device was 30 days (interquartile range, 5.5 to 145 days). At a median follow-up of 437.5 days (interquartile range, 13.8 to 1198 days), the mean pacing threshold (1.25±0.46 vs 1.58±0.66 volts, p=0.069) and impedance (383.81±70.33 vs 448.6±200.1 Ohms, p=0.168) remained stable compared with time of biventricular device connection. CONCLUSIONS A significant proportion of patients with poor LV function undergoing cardiac operations may benefit from concomitant LV lead implantation. Subsequent lead performance appears satisfactory. Epicardial LV lead placement is easily accomplished during open heart operations and should be considered before the operation.
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Affiliation(s)
- Leonard Shan
- Department of Cardiothoracic Surgery, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.
| | - Edward Buratto
- Department of Cardiothoracic Surgery, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Paul Conaglen
- Department of Cardiothoracic Surgery, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Philip Davis
- Department of Cardiothoracic Surgery, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Michael Yii
- Department of Cardiothoracic Surgery, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Ian Nixon
- Department of Cardiothoracic Surgery, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Andrew Newcomb
- Department of Cardiothoracic Surgery, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia; University of Melbourne Department of Surgery, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
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22
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Schroeter T, Borger MA, Mohr FW. Patent foramen ovale. Correct route for implantation of a biventricular permanent pacemaker? Herzschrittmacherther Elektrophysiol 2012; 23:141-3. [PMID: 22752355 DOI: 10.1007/s00399-012-0177-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 05/06/2012] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Intentional or unintentional placement of a pacemaker lead into the left ventricle is an uncommon clinical entity that is associated with a high risk for systemic embolization and enormous difficulties in case of explantation. Unintentional implantation through a patent foramen ovale via the mitral valve is the usual pathway for this malposition. METHODS We report a case where a pacemaker lead was placed intentionally into the left ventricle via a patent foramen ovale for biventricular pacing for resynchronization therapy. Later, the patient developed life-threatening pacemaker lead-associated endocarditis with sepsis. Emergency open heart surgery for lead removal was necessary in the form of a reoperation after bypass graft surgery a number of years earlier. CONCLUSION Although it is technically feasible to implant the pacemaker lead into the left ventricle via a patent foramen ovale, we consider this option to be obsolete for use with a biventricular pacemaker, due to the multitude of risks, which can, in part, be life-threatening for the patient.
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Affiliation(s)
- T Schroeter
- Department of Cardiac Surgery, Herzzentrum Leipzig, University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany.
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Kindermann M, Mahfoud F, Ukena C, Fröhlig G. [Cardiac resynchronization therapy: preoperative screening. How can we reliably predict response to CRT?]. Herzschrittmacherther Elektrophysiol 2011; 20:131-42. [PMID: 19672672 DOI: 10.1007/s00399-009-0053-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an established therapy for patients with advanced heart failure, depressed left ventricular function, and wide QRS complex. However, about 30 to 45% of patients do not respond to CRT. Assuming that the main therapeutic action of CRT is the correction of dyssynchronous myocardial contraction, a plethora of echocardiographic dyssynchrony parameters have been proposed to improve the prediction of response to CRT. However, one multicenter study has recently questioned the utility of any of these indexes. This review delineates the various causes of non-response to CRT, explains the different levels and mechanisms of dyssynchrony and gives a critical overview of currently available echocardiographic techniques for assessment of dyssynchrony. Based upon a discussion of the evidence coming from randomized multicenter studies and against the background of national and international cardiac societies' guideline recommendations on CRT, a rational basis for the evaluation of patients for CRT is proposed.
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Affiliation(s)
- M Kindermann
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str. 100, 66421, Homburg/Saar, Deutschland.
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24
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Davis MK, Virani SA. Cardiac resynchronization therapy in the cardiorenal syndrome. Int J Nephrol 2011; 2011:168461. [PMID: 21716684 PMCID: PMC3118524 DOI: 10.4061/2011/168461] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 03/21/2011] [Indexed: 12/15/2022] Open
Abstract
The cardiorenal syndrome (CRS) is a complex clinical syndrome in which dysfunction of either the heart or the kidneys affects the functioning of the other organ system. Many therapies used in heart failure have further detrimental effects on renal function. Cardiac resynchronization therapy (CRT) is a relatively new form of device therapy that reduces morbidity and mortality in patients with heart failure. This review will discuss the effects of CRT on renal function in patients with CRS, the impact of baseline renal function on response to CRT, and potential risks associated with CRT in this unique population.
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Affiliation(s)
- Margot K. Davis
- Division of Cardiology, Gordon and Leslie Diamond Health Care Centre, The University of British Columbia, Vancouver, BC, Canada V5Z 1M9
| | - Sean A. Virani
- Division of Cardiology, Gordon and Leslie Diamond Health Care Centre, The University of British Columbia, Vancouver, BC, Canada V5Z 1M9
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Miller AL, Kramer DB, Lewis EF, Koplan B, Epstein LM, Tedrow U. Event-free survival following CRT with surgically implanted LV leads versus standard transvenous approach. Pacing Clin Electrophysiol 2011; 34:490-500. [PMID: 21463344 PMCID: PMC3079428 DOI: 10.1111/j.1540-8159.2010.03014.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND While surgical epicardial lead placement is performed in a subset of cardiac resynchronization therapy patients, data comparing survival following surgical versus transvenous lead placement are limited. We hypothesized that surgical procedures would be associated with increased mortality risk. METHODS Long-term event-free survival was assessed for 480 consecutive patients undergoing surgical (48) or percutaneous (432) left ventricle (LV) lead placement at our institution from January 2000 to September 2008. RESULTS Baseline clinical and demographic characteristics were similar between groups. While there was no statistically significant difference in overall event-free survival (P = 0.13), when analysis was restricted to surgical patients with isolated surgical lead placement (n = 28), event-free survival was significantly lower in surgical patients (P = 0.015). There appeared to be an early risk (first approximately 3 months postimplantation) with surgical lead placement, primarily in LV lead-only patients. Event rates were significantly higher in LV lead-only surgical patients than in transvenous patients in the first 3 months (P = 0.006). In proportional hazards analysis comparing isolated surgical LV lead placement to transvenous lead placement, adjusted hazard ratios were 1.8 ([1.1,2.7] P = 0.02) and 1.3 ([1.0,1.7] P = 0.07) for the first 3 months and for the full duration of follow-up, respectively. CONCLUSIONS Isolated surgical LV lead placement appears to carry a small but significant upfront mortality cost, with risk extending beyond the immediate postoperative period. Long-term survival is similar, suggesting those surviving beyond this period of early risk derive the same benefit as coronary sinus lead recipients. Further work is needed to identify risk factors associated with early mortality following surgical lead placement.
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Affiliation(s)
- Amy L Miller
- Department of Medicine, Cardiovascular Division, Brigham & Women's Hospital, Boston, Massachusetts, USA.
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van Steenberghe M, Pruvot E, Delay D, Delacretaz E, Ruchat P. Insulation of the phrenic nerve as an alternative to left ventricular lead repositioning in cardiac resynchronization therapy. Int J Cardiol 2011; 147:328-9. [PMID: 21256608 DOI: 10.1016/j.ijcard.2010.12.087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 12/23/2010] [Indexed: 11/30/2022]
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KAMATH GANESHS, BALARAM SANDHYA, CHOI ANDREW, KUTEYEVA OLGA, GARIKIPATI NAGAVAMSI, STEINBERG JONATHANS, MITTAL SUNEET. Long-Term Outcome of Leads and Patients Following Robotic Epicardial Left Ventricular Lead Placement for Cardiac Resynchronization Therapy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 34:235-40. [DOI: 10.1111/j.1540-8159.2010.02943.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Merchant FM, Heist EK, McCarty D, Kumar P, Das S, Blendea D, Ellinor PT, Mela T, Picard MH, Ruskin JN, Singh JP. Impact of segmental left ventricle lead position on cardiac resynchronization therapy outcomes. Heart Rhythm 2010; 7:639-44. [PMID: 20298819 DOI: 10.1016/j.hrthm.2010.01.035] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Accepted: 01/22/2010] [Indexed: 11/18/2022]
Affiliation(s)
- Faisal M Merchant
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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Analysis of LV Lead Position in Cardiac Resynchronization Therapy Using Different Imaging Modalities. JACC Cardiovasc Imaging 2010; 3:472-81. [DOI: 10.1016/j.jcmg.2009.11.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Revised: 11/05/2009] [Accepted: 11/18/2009] [Indexed: 11/21/2022]
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Stanton CM, Asirvatham SJ, Bruce CJ, Danielsen A, Friedman PA. Future Developments in Nonsurgical Epicardial Therapies. Card Electrophysiol Clin 2010; 2:135-146. [PMID: 28770732 DOI: 10.1016/j.ccep.2009.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The unique anatomic position of the pericardium in juxtaposition to central cardiac structures enables it to serve as the ideal vantage point for the delivery of novel cardiovascular therapies. Development of new tools to permit delivery of therapy in the closed pericardial space holds promise for near-surgical access to the heart, without open surgical morbidity. Early observations raise hope for the availability of epicardial leads to enhance cardiac resynchronization therapy designed for subxiphoid nonsurgical percutaneous delivery. Emerging technologies for left atrial appendage ligation may offer new strategies for preventing stroke.
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Affiliation(s)
- Christopher M Stanton
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA
| | - Charles J Bruce
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA
| | | | - Paul A Friedman
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA
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Surgically placed left ventricular leads provide similar outcomes to percutaneous leads in patients with failed coronary sinus lead placement. Heart Rhythm 2010; 7:619-25. [PMID: 20156615 DOI: 10.1016/j.hrthm.2010.01.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Accepted: 01/11/2010] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy using a left ventricular (LV) lead inserted via the coronary sinus (CS) improves symptoms of congestive heart failure, decreases hospitalizations, and improves survival. An epicardial LV lead is often placed surgically after a failed percutaneous attempt, but whether it offers the same benefits is unknown. OBJECTIVE The purpose of this study was to determine if patients who receive a surgical LV lead after failed CS lead placement for cardiac resynchronization therapy derive the same benefit as do patients with a successfully placed CS lead. METHODS A total of 452 patients underwent attempted CS lead insertion. Forty-five patients who had failed CS lead placement and then had surgical LV lead placement were matched with 135 patients who had successful CS lead placement. RESULTS No major differences in preoperative variables were seen between groups. Postprocedural complications of acute renal injury (26.2% vs 4.9%, P <.001) and infection (11.9% vs 2.4%, P = .03) were more common in the surgical group. Mean long-term follow-up was 32.4 +/- 17.5 months for surgical patients and 39.4 +/- 14.8 months for percutaneous patients. At follow-up, all-cause mortality (30.6% vs 23.8%, P = .22) and readmission for congestive heart failure (26.2% vs 31.5%, P = .53) were similar between surgical and percutaneous groups. Improvement in New York Heart Association functional class (60.1% vs 49.6%, P = .17) was similar between surgical and percutaneous groups. CONCLUSION Surgical LV lead placement offers functional benefits similar to those of percutaneous placement but with greater risk of perioperative complications, including acute renal failure and infection.
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Kassab GS, Svendsen M, Combs W, Choy JS, Berbari EJ, Navia JA. A transatrial pericardial access: lead placement as proof of concept. Am J Physiol Heart Circ Physiol 2010; 298:H287-93. [DOI: 10.1152/ajpheart.00575.2009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A safe, easy, and quick access into the pericardial space may provide a window for diagnostics and therapeutics to the heart. The objective of this study was to provide proof of concept for an engagement and access catheter that allows access to the pericardial space percutaneously. A multilumen catheter was developed to allow navigation and suction fixation to the right atrial appendage/wall in a normal swine model. Advancement through the multilumen catheter using a second catheter with a distal needle tip allows access to the pericardial space without pericardial puncture and advancement of a standard guide wire into the space. Navigation into the pericardial space was undertaken by fluoroscopy alone and was accomplished in 10 swine (5 acute and 5 chronic). As a specific application of this pericardial access method, a pacing lead was implanted on the epicardial surface. Five chronic swine experiments were conducted with successful pacing engagement verified by lead impedance and pacing threshold and sensing. Lead impedance exceeded 1,000 Ω preengagement and dropped by an average of 200 Ω upon implant (769 ± 498 Ω). Pacing thresholds at 0.4 ms ranged from ∼0.5 to 2.1 V acutely (1.03 ± 0.92 V). No cardiac effusion or tamponade was observed in any of the acute or chronic studies. The ability to engage, maintain, and retract the right atrial appendage/wall and to engage an epicardial lead was successfully demonstrated. These findings support the feasibility of safe access into the pericardial space in a normal swine model and warrant further investigations for clinical translation.
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Affiliation(s)
- G. S. Kassab
- Departments of 1Biomedical Engineering,
- Surgery, and
- Cellular and Integrative Physiology, Indiana University Purdue University Indianapolis, Indianapolis; and
| | - M. Svendsen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana
| | - W. Combs
- Medtronic, Minneapolis, Minnesota; and
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LAU ERNESTW. Achieving Permanent Left Ventricular Pacing-Options and Choice. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:1466-77. [DOI: 10.1111/j.1540-8159.2009.02514.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Patwala A, Woods P, Clements R, Albouaini K, Rao A, Goldspink D, Tan LB, Oo A, Wright D. A prospective longitudinal evaluation of the benefits of epicardial lead placement for cardiac resynchronization therapy. Europace 2009; 11:1323-9. [DOI: 10.1093/europace/eup251] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lau EW. A streamlined technique of trans-septal endocardial left ventricular lead placement. J Interv Card Electrophysiol 2009; 26:73-81. [DOI: 10.1007/s10840-009-9395-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 03/02/2009] [Indexed: 10/20/2022]
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Shafy A, Lavergne T, Latremouille C, Cortes-Morichetti M, Carpentier A, Chachques JC. Association of electrostimulation with cell transplantation in ischemic heart disease. J Thorac Cardiovasc Surg 2009; 138:994-1001. [PMID: 19660354 DOI: 10.1016/j.jtcvs.2009.02.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 01/02/2009] [Accepted: 02/03/2009] [Indexed: 01/16/2023]
Abstract
BACKGROUND Until now, cell therapy has constituted a passive therapeutic approach; the only effects seem to be related to the reduction of the myocardial fibrosis and the limitation of the adverse ventricular remodeling. Cardiac resynchronization therapy is indicated in patients with heart failure to correct conduction disorders associated with chronic systolic and diastolic dysfunction. The association of electrostimulation with cellular cardiomyoplasty could be a way to transform passive cell therapy into "dynamic cellular support." Electrostimulation of ventricles following skeletal myoblast implantation should induce the contraction of the transplanted cells and a higher expression of slow myosin, which is better adapted for chronic ventricular assistance. The purpose of this study is to evaluate myogenic cell transplantation in an ischemic heart model associated with cardiac resynchronization therapy. METHODS Twenty two sheep were included. All animals underwent myocardial infarction by ligation of 2 coronary artery branches (distal left anterior descending artery and D2). After 4 weeks, autologous cultured myoblasts were injected in the infarcted areas with or without pacemaker implantation. Atrial synchronized biventricular pacing was performed using epicardial electrodes. Echocardiography was performed at 4 weeks (baseline) and 12 weeks after infarction. RESULTS Echocardiography showed a significant improvement in ejection fraction and limitation of left ventricular dilatation in cell therapy with cardiac resynchronization therapy as compared with the other groups. Viable cells were identified in the infarcted areas. Differentiation of myoblasts into myotubes and enhanced expression of slow myosin heavy chain was observed in the electrostimulated group. Transplantation of cells with cardiac resynchronization therapy caused an increase in diastolic wall thickening in the infarcted zone relative to cells-only group and cardiac resynchronization therapy-only group. CONCLUSIONS Biventricular pacing seems to induce synchronous contraction of transplanted myoblasts and the host myocardium, thus improving ventricular function. Electrostimulation was related with enhanced expression of slow myosin and the organization of myoblasts in myotubes, which are better adapted at performing cardiac work. Patients with heart failure presenting myocardial infarct scars and indication for cardiac resynchronization therapy might benefit from simultaneous cardiac pacing and cell therapy.
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Affiliation(s)
- Abdel Shafy
- Laboratory of Biosurgical Research, Pompidou Hospital, University of Paris, Paris, France
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