Elsevier

Heart Rhythm

Volume 7, Issue 5, May 2010, Pages 619-625
Heart Rhythm

Clinical
Device
Surgically placed left ventricular leads provide similar outcomes to percutaneous leads in patients with failed coronary sinus lead placement

https://doi.org/10.1016/j.hrthm.2010.01.014Get rights and content

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.

Introduction

Cardiac resynchronization therapy (CRT) improves symptoms of congestive heart failure (CHF), increases exercise tolerance, and decreases hospital readmission. Furthermore, CRT improves ejection fraction (EF) and survival.1, 2 Most of these data are derived from large trials using a transvenous approach placing the left ventricular (LV) lead via the coronary sinus (CS). Although this approach is least invasive, it can be challenging due to limitations in CS anatomy, epicardial scar, and unintended stimulation of the left phrenic nerve.3 Due to these restrictions, success rates of the percutaneous approach are 75% to 93%.1

In cases where percutaneous LV lead insertion is unsuccessful, an alternative surgical placement of an epicardial LV lead can be performed via minithoracotomy, video-assisted thoracoscopy (VATS), or with robotic assistance.4 Surgical LV lead placement is not without risk, as the procedure requires a general anesthetic and often single-lung ventilation, adding strain to these already severely compromised patients.

Although one small trial demonstrated that surgical placement of epicardial LV leads improves symptoms as well as CS lead placement at 6 months, whether epicardial LV lead placement after failed transvenous percutaneous approach improves survival or symptoms in the long term is not known.5 Therefore, the objective of this study was to compare the long-term outcomes of patients undergoing surgical LV lead placement following failed percutaneous lead insertion with similar patients who had successful percutaneous LV lead insertion. We hypothesized that patients in whom surgical LV lead placement was performed derive the same benefit from CRT as do patients with percutaneously placed leads.

Section snippets

Study population

Approval for this investigation was obtained by the Human Investigation Committee of the University of Virginia Health System (IRB No. 13619), including a waiver for the need to obtain patient consent. A total of 452 patients underwent attempted insertion of biventricular pacing for CRT from January 2000 to December 2007 at the University of Virginia. All patients met accepted CRT guidelines,6 including depressed EF (<35%), advanced heart failure (New York Heart Association [NYHA] functional

Demographics

Baseline demographics for surgical and percutaneous patients are listed in Table 1. Mean duration between failed percutaneous attempt and surgical LV lead placement was 25.6 ± 42.6 days. Preoperative variables including age, EF, NYHA class, and QRS duration were similar. The etiology of heart failure (ischemic vs nonischemic) also was similar. The proportion of patients with prior cardiac operation, including coronary artery bypass grafting, was not different. Peripheral vascular disease was

Discussion

CRT has been well documented to improve LV EF, heart failure symptoms, and survival.1, 7, 8, 9, 10 Although percutaneous lead placement with a CS lead is the first-line approach, it has been limited by failed lead implantation rates of 7% to 25%,1, 11, 12 Under these circumstances, patients are often referred for surgical LV leads, but a paucity of long-term data is available for this approach. In the present study, we observed an 11.3% failure rate for percutaneous attempts at LV lead

Study limitations

Our study has several limitations. First, the study was retrospective with a heterogeneous patient population. We attempted to account for these differences by using propensity matching of the critical risk factors (EF, QRS width, age) known to be associated with mortality. In addition, although the mean follow-up in our study (38 months) is longer than what is reported in the literature, longer follow-up could show further differences between percutaneous and surgical leads. The potential for

Conclusion

We demonstrated that in patients with indications for biventricular pacing and failed percutaneous leads, surgical lead placement likely will provide benefit to these patients. Surgical LV lead insertion can be performed with acceptable morbidity and mortality. Importantly, surgical lead placement following failed percutaneous attempt is justified, as surgical leads confer similar functional benefits, short and long-term survival, and readmission rates for CHF compared to primary percutaneous

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  • Cited by (0)

    The first two authors contributed equally to this manuscript.

    This project was supported by NIH Award Number T32HL007849 from the National Heart, Lung, And Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, And Blood Institute or the National Institutes of Health.

    This study was supported by a Thoracic Surgery Foundation for Research and Education Research Grant to Dr. Ailawadi and by National Institutes of Health (NIH) T32 Training Grant (HL007849) for Dr. LaPar. Portions of the manuscript were presented at the American Heart Association annual scientific sessions, November 12, 2008, New Orleans, Louisiana.

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