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.