Robotically assisted left ventricular epicardial lead implantation for biventricular pacing

OBJECTIVES: Ventricular resynchronization might be achieved in a minimally invasive fashion using a robotically assisted, direct left ventricular (LV) epicardial approach. BACKGROUND: Approximately 10% of patients undergoing biventricular pacemaker insertion have a failure of coronary sinus (CS) cannulation. Rescue therapy for these patients currently is limited to standard open surgical techniques. METHODS: Ten patients with congestive heart failure (New York Heart Association class 3.4 ± 0.5) and a widened QRS complex (184 ± 31 ms) underwent robotic LV lead placement after failed CS cannulation. Mean patient age was 71 ± 12 years, LV ejection fraction (EF) was 12 ± 6%, and LV end-diastolic diameter was 7.1 ± 1.3 cm. Three patients had previous cardiac surgery, and five patients had a prior device implanted. RESULTS: Nineteen epicardial leads were successfully placed on the posterobasal surface of the LV. Intraoperative lead threshold was 1.0 ± 0.5 V at 0.5 ms, R-wave was 18.6 ± 8.6 mV, and impedance was 1,143 ± 261 ohms at 0.5 V. Complications included an intraoperative LV injury and a postoperative pneumonia. Improvements in exercise tolerance (8 of 10 patients), EF (19 ± 13%, p = 0.04), and QRS duration (152 ± 21 ms, p = 0.006) have been noted at three to six months follow-up. Lead thresholds have remained unchanged (2.1 ± 1.4 V at 0.5 ms, p = NS), and a significant drop in impedance (310 ± 59 ohms, p < 0.001) has been measured. CONCLUSIONS: Robotic LV lead placement is an effective and novel technique which can be used for ventricular resynchronization therapy in patients with no other minimally invasive options for biventricular pacing.