© 2014 Wiley Periodicals, Inc.
290
SURGICAL TECHNIQUE ___________________________________________________________
Direct Transapical Implantation of an Endocardial Pacing Lead to the Left Ventricle: An Alternate Pacing Site After Tricuspid Valve Replacement _ CinS Koray Ak, M.D.,* Selim Isbir, M.D.,* Altug S cin, M.D.,y Alper Kararmaz, M.D.,z and Sinan Arsan, M.D.* *Department of Cardiovascular Surgery, Marmara University School of Medicine, Istanbul, Turkey; yDepartment of Cardiology, Marmara University School of Medicine, Istanbul, Turkey; and zDepartment of Anesthesiology and Reanimation, Marmara University School of Medicine, Istanbul, Turkey ABSTRACT In this paper, we report an alternative approach for implantation of ventricular pacing lead for complete atrioventricular block after tricuspid valve replacement. doi: 10.1111/jocs.12288 (J Card Surg
2014;29:290–292)
The need for permanent pacemaker implantation in patients with tricuspid valve replacement (TVR) is still high and ventricular pacing in these patients has routinely been achieved by implanting epicardial leads surgically or through the coronary sinus (CS).1 When these commonly preferred ways fail after TVR, alternative surgical approaches for pacing should be kept in the surgeon’s armamentarium. In this report, we describe an alternate pacing site after TVR. SURGICAL TECHNIQUE A 24-year-old female patient underwent TVR with a mechanical bileaflet mitral valve (Sorin Bicarbon, Milano, Italy) and partial resection of the pulmonary valve leaflets for endocarditis involving both the tricuspid and pulmonary valves. During the weaning from cardiopulmonary bypass (CPB), the rhythm was normal sinus with a rate of 86 bpm. On the fourth postoperative day, complete atrioventricular (AV) block developed with a ventricular rate of 35 bpm. Ventricular pacing was started at a rate of 80 bpm via a transient right ventricular epicardial pacing wire placed at the Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Koray Ak, M.D., Marmara Universitesi itim ve Arastirma Hastanesi, Kalp ve Damar Cerrahisi klinigi, Pendik Eg 4. Kat, Ustkaynarca Pendik, Istanbul, Turkey. Fax: 00902166570606; e-mail: [email protected]
time of TVR. Despite waiting for 10 days, the rhythm remained unchanged. A permanent epicardial unipolar ventricular lead (CapSure 5071, Medtronic, Minneapolis, MN, USA) was fixed to the diaphragmatic surface of the right ventricle through a partial lower miniresternotomy and the pulse generator was placed into the rectus sheath. At implantation time, pacing measurements were R wave ¼ 4 mV, ventricular threshold ¼ 1 V at 0.4 ms, and impedance ¼ 625 Ohm. The postoperative course after implantation of the permanent epicardial lead was complicated by respiratory dysfunction. The patient was discharged from the hospital on postoperative day 30. She was readmitted to the emergency department due to syncope three months after discharge. On admission, initial evaluation showed complete AV block (ventricular rate: 38 bpm) related to ventricular lead dysfunction. Pacing measurements revealed a ventricular threshold of 7.5 V at 1.5 ms and impedance was 928 Ohm. Insertion of a left ventricular epicardial lead through the CS was planned. Due to the lack of the necessary equipment for CS catheterization an urgent surgical procedure for pacing was planned. Under general anesthesia, a left anterolateral mini-thoracotomy through the fifth intercostal space was performed and dense epicardial adhesions were released. Though multiple epicardial sites on the lateral and the diaphragmatic walls were tested for mapping, the sensing and pacing thresholds were unacceptably high. It was decided to proceed with transapical insertion of a pacing electrode lead into the endocardium of left ventricle.
J CARD SURG 2014;29:290–292
AK, ET AL. DIRECT TRANSAPICAL LV PACING
Figure 1. Intraoperative view showing the ventricular lead implanted transapically.
After systemic heparinization, the apex was punctured and an atrial epicardial passive lead (CapSure Z Novus 5594, Medtronic) was advanced into the left ventricle. The lead was fixed to the apex by using a 5/0 prolene suture (Fig. 1). We recorded the following measurements: R wave ¼ 8 mV, ventricular threshold ¼ 0.6 V at 0.4 ms, and impedance ¼ 430 Ohm. The lead was connected to the battery within the rectus sheath and the patient was successfully paced. The position of the lead was confirmed by chest X-ray and transthoracic echocardiography (TTE) (Fig. 2A and B). Due to the mechanical prosthesis used for TVR, the patient was anticoagulated with warfarin. Her postoperative course was uneventful. COMMENT Endocardial right ventricular lead implantation has been shown to be associated with the potential risk of valve dysfunction including direct lead interference with valve closure and perforation or laceration of valve leaflets after TVR.1
291
Ventricular pacing through the CS has been shown to be safe and effective in patients with a prosthetic tricuspid valve. It is also a minimally invasive approach and the success rates of satisfactory sensing and pacing through the CS have been reported to be over 90% in cardiac resynchronization therapy (CRT).2 However there are some drawbacks for the CS pacing such as diaphragmatic stimulation, CS dissection, and high threshold for pacing.3 Mair et al.4 compared the surgical epicardial lead implantation with the CS technique for biventricular pacing. They concluded that epicardial pacing is more reliable in terms of correct lead positioning, lead-related complications, and unfavorable alterations in threshold capture during follow-up. In patients with prior cardiac surgery, pericardial adhesions may preclude the use of the epicardial approach because of the excessive pacing thresholds and high incidence of exit block. Also, the risk for fatal bleeding should not be underestimated. Placing two, instead of one, epicardial leads for complete AV block developing immediately after TVR or at the early postoperative period should be routinely advised to prevent the need for further reoperation related to pacemaker dysfunction. In our patient an atrial endocardial pacing lead was preferred due to the presence of reverse J-shaped configuration and the tines on the lead that were thought to provide better anchoring to the trabeculations of the left ventricle. Left ventricular endocardial lead implantation through the transseptal approach has been shown to be an alternative and safe way if the CS technique fails for CRT.3 The technique of direct transapical lead implantation through a left thoracotomy incision was firstly described for CRT by Kassai et al.5 Although our technique does not seem universally applicable in the era of easily applicable percutaneous approaches, direct transapical implantation of an endocardial pacing lead might be an option for emergency ventricular pacing when other methods fail. Additionally, thromboembolic complications are not a great concern in anticoagulated patients. However, long-term followup with attention to thromboembolic and infectious complications is mandatory.
Figure 2. (A) Chest X-ray of the patient (a: old epicardial lead on the right ventricle, b: transapical left ventricular lead, and c: pacemaker battery in the rectus sheath). (B) Transthoracic echocardiographic view showing the tip of the pacing lead in the left ventricle.
292
AK, ET AL. DIRECT TRANSAPICAL LV PACING
REFERENCES 1. Jokinen JJ, Turpeinen AK, Pitk€ anen O, et al: Pacemaker therapy after tricuspid valve operations: Implications on mortality, morbidity, and quality of life. Ann Thorac Surg 2009;87:1806–1814. 2. Luedorff G, Kranig W, Grove R, et al: Improved success rate of cardiac resynchronization therapy implant by employing an active fixation coronary sinus lead. Europace 2010;12:825–829. JL, Massin F, Macia JC, et al: Long-term follow-up 3. Pasquie of biventricular pacing using a totally endocardial approach
J CARD SURG 2014;29:290–292
in patients with end-stage cardiac failure. Pacing Clin Electrophysiol 2007;30:S31–S33. 4. Mair H, Sachweh J, Meuris B, et al: Surgical epicardial left ventricular lead versus coronary sinus lead placement in biventricular pacing. Eur J Cardiothorac Surg 2005;27:235– 242. 5. Kassai I, Foldesi C, Szekely A, et al: New method for cardiac resynchronization therapy: Transapical endocardial lead implantation for left ventricular free wall pacing. Europace 2008;10:882–883.
290
SURGICAL TECHNIQUE ___________________________________________________________
Direct Transapical Implantation of an Endocardial Pacing Lead to the Left Ventricle: An Alternate Pacing Site After Tricuspid Valve Replacement _ CinS Koray Ak, M.D.,* Selim Isbir, M.D.,* Altug S cin, M.D.,y Alper Kararmaz, M.D.,z and Sinan Arsan, M.D.* *Department of Cardiovascular Surgery, Marmara University School of Medicine, Istanbul, Turkey; yDepartment of Cardiology, Marmara University School of Medicine, Istanbul, Turkey; and zDepartment of Anesthesiology and Reanimation, Marmara University School of Medicine, Istanbul, Turkey ABSTRACT In this paper, we report an alternative approach for implantation of ventricular pacing lead for complete atrioventricular block after tricuspid valve replacement. doi: 10.1111/jocs.12288 (J Card Surg
2014;29:290–292)
The need for permanent pacemaker implantation in patients with tricuspid valve replacement (TVR) is still high and ventricular pacing in these patients has routinely been achieved by implanting epicardial leads surgically or through the coronary sinus (CS).1 When these commonly preferred ways fail after TVR, alternative surgical approaches for pacing should be kept in the surgeon’s armamentarium. In this report, we describe an alternate pacing site after TVR. SURGICAL TECHNIQUE A 24-year-old female patient underwent TVR with a mechanical bileaflet mitral valve (Sorin Bicarbon, Milano, Italy) and partial resection of the pulmonary valve leaflets for endocarditis involving both the tricuspid and pulmonary valves. During the weaning from cardiopulmonary bypass (CPB), the rhythm was normal sinus with a rate of 86 bpm. On the fourth postoperative day, complete atrioventricular (AV) block developed with a ventricular rate of 35 bpm. Ventricular pacing was started at a rate of 80 bpm via a transient right ventricular epicardial pacing wire placed at the Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Koray Ak, M.D., Marmara Universitesi itim ve Arastirma Hastanesi, Kalp ve Damar Cerrahisi klinigi, Pendik Eg 4. Kat, Ustkaynarca Pendik, Istanbul, Turkey. Fax: 00902166570606; e-mail: [email protected]
time of TVR. Despite waiting for 10 days, the rhythm remained unchanged. A permanent epicardial unipolar ventricular lead (CapSure 5071, Medtronic, Minneapolis, MN, USA) was fixed to the diaphragmatic surface of the right ventricle through a partial lower miniresternotomy and the pulse generator was placed into the rectus sheath. At implantation time, pacing measurements were R wave ¼ 4 mV, ventricular threshold ¼ 1 V at 0.4 ms, and impedance ¼ 625 Ohm. The postoperative course after implantation of the permanent epicardial lead was complicated by respiratory dysfunction. The patient was discharged from the hospital on postoperative day 30. She was readmitted to the emergency department due to syncope three months after discharge. On admission, initial evaluation showed complete AV block (ventricular rate: 38 bpm) related to ventricular lead dysfunction. Pacing measurements revealed a ventricular threshold of 7.5 V at 1.5 ms and impedance was 928 Ohm. Insertion of a left ventricular epicardial lead through the CS was planned. Due to the lack of the necessary equipment for CS catheterization an urgent surgical procedure for pacing was planned. Under general anesthesia, a left anterolateral mini-thoracotomy through the fifth intercostal space was performed and dense epicardial adhesions were released. Though multiple epicardial sites on the lateral and the diaphragmatic walls were tested for mapping, the sensing and pacing thresholds were unacceptably high. It was decided to proceed with transapical insertion of a pacing electrode lead into the endocardium of left ventricle.
J CARD SURG 2014;29:290–292
AK, ET AL. DIRECT TRANSAPICAL LV PACING
Figure 1. Intraoperative view showing the ventricular lead implanted transapically.
After systemic heparinization, the apex was punctured and an atrial epicardial passive lead (CapSure Z Novus 5594, Medtronic) was advanced into the left ventricle. The lead was fixed to the apex by using a 5/0 prolene suture (Fig. 1). We recorded the following measurements: R wave ¼ 8 mV, ventricular threshold ¼ 0.6 V at 0.4 ms, and impedance ¼ 430 Ohm. The lead was connected to the battery within the rectus sheath and the patient was successfully paced. The position of the lead was confirmed by chest X-ray and transthoracic echocardiography (TTE) (Fig. 2A and B). Due to the mechanical prosthesis used for TVR, the patient was anticoagulated with warfarin. Her postoperative course was uneventful. COMMENT Endocardial right ventricular lead implantation has been shown to be associated with the potential risk of valve dysfunction including direct lead interference with valve closure and perforation or laceration of valve leaflets after TVR.1
291
Ventricular pacing through the CS has been shown to be safe and effective in patients with a prosthetic tricuspid valve. It is also a minimally invasive approach and the success rates of satisfactory sensing and pacing through the CS have been reported to be over 90% in cardiac resynchronization therapy (CRT).2 However there are some drawbacks for the CS pacing such as diaphragmatic stimulation, CS dissection, and high threshold for pacing.3 Mair et al.4 compared the surgical epicardial lead implantation with the CS technique for biventricular pacing. They concluded that epicardial pacing is more reliable in terms of correct lead positioning, lead-related complications, and unfavorable alterations in threshold capture during follow-up. In patients with prior cardiac surgery, pericardial adhesions may preclude the use of the epicardial approach because of the excessive pacing thresholds and high incidence of exit block. Also, the risk for fatal bleeding should not be underestimated. Placing two, instead of one, epicardial leads for complete AV block developing immediately after TVR or at the early postoperative period should be routinely advised to prevent the need for further reoperation related to pacemaker dysfunction. In our patient an atrial endocardial pacing lead was preferred due to the presence of reverse J-shaped configuration and the tines on the lead that were thought to provide better anchoring to the trabeculations of the left ventricle. Left ventricular endocardial lead implantation through the transseptal approach has been shown to be an alternative and safe way if the CS technique fails for CRT.3 The technique of direct transapical lead implantation through a left thoracotomy incision was firstly described for CRT by Kassai et al.5 Although our technique does not seem universally applicable in the era of easily applicable percutaneous approaches, direct transapical implantation of an endocardial pacing lead might be an option for emergency ventricular pacing when other methods fail. Additionally, thromboembolic complications are not a great concern in anticoagulated patients. However, long-term followup with attention to thromboembolic and infectious complications is mandatory.
Figure 2. (A) Chest X-ray of the patient (a: old epicardial lead on the right ventricle, b: transapical left ventricular lead, and c: pacemaker battery in the rectus sheath). (B) Transthoracic echocardiographic view showing the tip of the pacing lead in the left ventricle.
292
AK, ET AL. DIRECT TRANSAPICAL LV PACING
REFERENCES 1. Jokinen JJ, Turpeinen AK, Pitk€ anen O, et al: Pacemaker therapy after tricuspid valve operations: Implications on mortality, morbidity, and quality of life. Ann Thorac Surg 2009;87:1806–1814. 2. Luedorff G, Kranig W, Grove R, et al: Improved success rate of cardiac resynchronization therapy implant by employing an active fixation coronary sinus lead. Europace 2010;12:825–829. JL, Massin F, Macia JC, et al: Long-term follow-up 3. Pasquie of biventricular pacing using a totally endocardial approach
J CARD SURG 2014;29:290–292
in patients with end-stage cardiac failure. Pacing Clin Electrophysiol 2007;30:S31–S33. 4. Mair H, Sachweh J, Meuris B, et al: Surgical epicardial left ventricular lead versus coronary sinus lead placement in biventricular pacing. Eur J Cardiothorac Surg 2005;27:235– 242. 5. Kassai I, Foldesi C, Szekely A, et al: New method for cardiac resynchronization therapy: Transapical endocardial lead implantation for left ventricular free wall pacing. Europace 2008;10:882–883.
