Thoracoscopic epicardial lead implantation as an alternative to failed endovascular insertion for cardiac pacing and resynchronization therapy

Objective: Numerous anomalies or postprocedural stricture of the venous system prevent optimal endovascular implantation of a pacing lead in more than 10% of patient indicated for permanent pacing or cardiac resynchronization therapy. The purpose of this report was to summarize our experience and immediate postoperative results of thoracoscopic lead implantation as a lesser invasive solution to an unsuccessful endovascular lead insertion. ' Methods: From January 2008 to April 2013, 11 epicardial leads were introduced thoracoscopically at our center as a rescue treatment after failed endovascular attempts. Patients were ventilated using a doublelumen endotracheal tube. A 5-mm 30-degree lance thoracoscope was used with either 2 or 3 additional working ports. A screw-in pacing lead (Medtronic Model 5071 Pacing lead, Minneapolis, MN USA) was inserted into the left ventricular epicardium. After the lead placement and assessment for threshold less than 1 V, the lead was brought to the chest wall and tunneled to the pacemaker generator pocket. At the end of the procedure, a small, flexible 14F thoracic drain, was left inside the pleural cavity for the next 24 hours. ' Results: Therewere no mortality or any major surgical complications among these patients. All patients responded to the epicardial lead implantation in terms of appropriate pacing and conductivity. No clinical failure was observed, and no patient required a repeat procedure. ' Conclusions: Thoracoscopic lead insertion is safe and easy to perform. We believe it should be offered as the first choice after failed endovascular pacing lead implantation.