Comparison of left ventricular lead placement via the coronary venous approach versus lateral thoracotomy in patients receiving cardiac resynchronization therapy

https://doi.org/10.1016/j.amjcard.2004.03.031Get rights and content

Abstract

Cardiac resynchronization therapy (CRT) is a new therapeutic option in patients with heart failure and ventricular conduction delay. We compared the long-term performance of left ventricular (LV) pacing via the coronary venous (CV) approach and a limited lateral thoracotomy (LLT). Data from 81 patients (age 65 ± 12 years; 52 men, New York Heart Association class 3.0 ± 0.4, ejection fraction 24 ± 6%) were retrospectively analyzed for 1 year after implantation of a CRT system. Twenty-five patients received LLT leads and 56 patients received CV leads. Postoperative hospitalization was shorter after CV lead implantation (8 ± 4 vs 12 ± 5 days, p <0.01). No significant differences in LV pacing and sensing performance between both approaches were observed after 12 months. Reinterventions were necessary in 7 patients after CV implantation compared with only 1 reintervention (4%) in the LLT group (p = NS). Postoperative chest radiographs revealed an anterior lead position in 11 of 25 patients (44%) in the LLT group versus 3 of 56 patients (5.4%) in the CV group (p = 0.00007). Echocardiographic data demonstrated a sig-nificant increase in LV ejection fraction in the CV group (from 26.1 ± 5.2% to 35.3 ± 14.3% at 12 months, p <0.001, n = 42) in contrast to the LLT group (from 24.5 ± 6.2% to 28.5 ± 7.5% at 12 months, p = NS, n = 16) at 12-month follow-up. Cardiopulmonary exercise testing in 35 patients showed significantly more improvement in peak oxygen consumption after 12 months in the CV group (15.5 ± 3.1 vs 13.6 ± 2.6 ml/min/kg at implant, n = 22) compared with the LLT group (12.7 ± 1.5 vs 11.8 ml/min/kg at implant, n = 13, p = 0.004). At 1-year follow-up the mortality rate was 24% (6 of 25) after LLT lead implantation versus 12.5% (7 of 56) after CV implantation (p = NS). Our data show that the LLT approach for LV lead placement in CRT systems has the advantage of a lower incidence of reinterventions. Hospitalization was longer, increase in functional capacity smaller, and mortality at 1-year follow-up higher, which were potentially related to a more anterior lead position. Therefore, CV leads are preferable to LLT leads.

Section snippets

Study population

Between January 1997 and March 2002, 81 patients received a CRT system, including a lead for LV pacing. Twenty-five patients received LLT leads due to unavailability of CV leads (n = 24) or due to failure of the CV approach (n = 1). When transvenous leads became available in 1999, LV pacing was achieved in 56 patients by positioning a lead into a branch of the coronary sinus venous system. There were no significant differences between patients of both the LLT and CV groups (Table 1).

Implantation procedure

The LLT

CV group versus LLT group

Eighty-one patients received a CRT system. Patient characteristics according to implantation technique are listed in Table 1. CV lead implantation was successful in 56 of 57 patients (98%) in whom it was attempted. One patient developed a dissection of the coronary sinus without hemodynamic complications and received a LLT lead.

In 25 patients, LLT leads were implanted due to unavailability of CV leads (n = 24) or unsuccessful CV lead placement (n = 1). Implant durations were not significantly

Discussion

This study confirms that CV lead implantation is feasible with a success rate of about 98%, which correlates with the range of 81% to 99% reported in earlier studies.6, 7, 8, 9, 10, 11 Perioperative morbidity was low, and there was no procedure-related mortality, irrespective of the surgical approach for implanting the LV lead. The main advantage of the CV approach is that it is less invasive in this patient population, with a high perioperative risk due to advanced heart failure. This

References (18)

There are more references available in the full text version of this article.

Cited by (0)

View full text