P512New approaches to pacing in children with atrioventricular block

Abstract Introduction The placement of permanent pacemaker is presented as one of the most appropriate procedures in patients with congenital complete atrioventricular block (AVB). Despite video-assisted thoracic surgery (VATS) for epicardial lead placement has demonstrated positive results concerning the feasibility and freedom of complications in adults, its role in pacemaker implantation in children remains unclear. The study aimed to assess the intermediate-term outcomes of video-assisted thoracic pacing in children with congenital complete AVB. Methods From May 2017 to November 2018, six children with complete idiopathic AVB underwent minimally invasive left ventricular lead placements via thoracoscopic video assistance. The procedure was performed under complex intratracheal anesthesia with single-lung ventilation, median operation time was 180 minutes (120–240). Four incisions were made, three of them were used to place the lead on the left ventricular, and one was needed to place the device. All pacing parameters were evaluated in perioperative and follow-up periods. Results Median age at implantation was 3 years (2 to 15 years), median weight 13 kg (12–46 kg). All procedures were completed successfully, pacing thresholds for the active lead measured 0.5-1.1V, with R-wave amplitude of 8-18 mV and impedance of 404-1478 Ohm. Increasing pacing thresholds in the third month after pacemaker implantation occurred in one patient, so anti-inflammatory therapy was assigned. Satisfactory thresholds and impedances with no significant difference with initial values were obtained at the median follow-up of 21 months (range: 10–28 months). Conclusion Video-assisted thoracic pacing may provide a potential alternative to the transthoracic approach of epicardial lead placement in children with congenital AVB.

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Is alcohol septal ablation in women performed too late?

European Heart Journal ◽

10.1093/ehjci/ehaa946.2077 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Batzner ◽

D Aicha ◽

H Seggewiss

Keyword(s):

Hospital Stay ◽

Pacemaker Implantation ◽

Posterior Wall ◽

Hypertrophic Obstructive Cardiomyopathy ◽

Left Ventricular ◽

Icd Implantation ◽

Alcohol Septal Ablation ◽

Significant Difference ◽

Surgical Myectomy

Abstract Introduction Alcohol septal ablation (PTSMA) was introduced as interventional alternative to surgical myectomy for symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) 25 years ago. As gender differences in diagnosis and treatment of HOCM are still unclear we analyzed baseline characteristics and results of PTSMA in a large single center cohort with respect to gender. Methods and results Between 05/2000 and 06/2017 first PTSMA in our center was performed in 952 patients with symptomatic HOCM. We treated less 388 (40.8%) women and 564 (59.2%) men. All patients underwent clinical follow-up. At the time of the intervention women were older (61.2±14.9 vs. 51.9±13.7 years; p<0.0001) and suffered more often from NYHA grade III/IV dyspnea (80.9% vs. 68.1%; p<0.0001), whereas angina pectoris was comparable in women (62.4%) and men (59.9%). Echocardiographic baseline gradients were comparable in women (rest 65.0±38.1 mmHg and Valsalva 106.2±45.7 mmHg) and men (rest 63.1±38.3 mmHg and Valsalva 103.6±42.8 mmHg). But, women had smaller diameters of the left atrium (44.3±6.9 vs. 47.2±6.5 mm; p<0001), maximal septum thickness (20.4±3.9 vs. 21.4±4.5 mm; p<0.01), and maximal thickness of the left ventricular posterior wall (12.7±2.8 vs. 13.5±2.9 mm; p<0.0001). In women, more septal branches (1.3±0.6 vs. 1.2±0.5; p<0.05) had to be tested to identify the target septal branch. The amount of injected alcohol was comparable (2.0±0, 4 in women vs. 2.1±0.4 ml in men). The maximum CK increase was lower in women (826.0±489.6 vs. 903.4±543.0 U / l; p<0.05). During hospital stay one woman and one man died, each (n.s.). The frequency of total AV blocks in the cathlab showed no significant difference between women (41.5%) and men (38.3%). Furthermore, the rate of permanent pacemaker implantation during hospital stay did not differ (12.1% in women vs. 9.4% in men). Follow-up periods of all patients showed no significant difference between women (5.7±4.9 years) and men (6.2±5.0 years). Overall, 37 (9.5%) women died during this period compared to only 33 (5.9%) men (p<0.05). But, cardiovascular causes of death were not significantly different between women (2.8%) and men (1.6%). Furthermore, the rates of surgical myectomy after failed PTSMA (1.3% in women vs. 2.3% in men), ICD implantation for primary prevention of sudden cardiac death according to current guidelines (4.1% in women vs. 5.9% in men) or pacemaker implantation (3.6% in women vs. 2.0% in men) showed no significant differences. Summary PTSMA in women with HOCM was performed at more advanced age with more pronounced symptoms compared to men. While there were no differences in acute outcomes, overall long-term mortality was higher in women without differences in cardiovascular mortality. Therefore, women may require more intensive diagnostic approaches in order not to miss the correct time for gradient reduction treatment. Funding Acknowledgement Type of funding source: None

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Transesophageal Echocardiography–Guided Epicardial Left Ventricular Lead Placement by Video-Assisted Thoracoscopic Surgery in Nonresponders to Biventricular Pacing and Previous Chest Surgery

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/155698451801300309 ◽

2018 ◽

Vol 13 (3) ◽

pp. 211-217

Author(s):

Carsten Schroeder ◽

Jane M. Chung ◽

Judith A. Mackall ◽

Ivan T. Cakulev ◽

Aaron Patel ◽

...

Keyword(s):

Transesophageal Echocardiography ◽

Thoracoscopic Surgery ◽

Biventricular Pacing ◽

Left Ventricular ◽

Left Ventricular Lead ◽

Video Assisted ◽

Lead Placement ◽

Ventricular Lead ◽

Left Ventricular Lead Placement ◽

Video Assisted Thoracoscopic Surgery

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0300: A Short-Term Follow-Up Study of Left Ventricular Epicardial Lead Placement for Cardiac Resynchronization Therapy

Ultrasound in Medicine & Biology ◽

10.1016/j.ultrasmedbio.2009.06.146 ◽

2009 ◽

Vol 35 (8) ◽

pp. S38

Author(s):

Ye Zhang ◽

Zhian Li ◽

Yihua He ◽

Ya Yang ◽

Xiaoyan Gu ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Resynchronization Therapy ◽

Short Term ◽

Follow Up Study ◽

Epicardial Lead ◽

Lead Placement

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Cardiac Resynchronisation Therapy – An Approach to Difficult Left Ventricular Lead Placement

European Journal of Arrhythmia & Electrophysiology ◽

10.17925/ejae.2015.01.01.25 ◽

2015 ◽

Vol 01 (01) ◽

pp. 25 ◽

Cited By ~ 1

Author(s):

Mayank Singhal ◽

Manoj K Rohit ◽

Parag Barwad ◽

◽

...

Keyword(s):

Cardiac Resynchronisation Therapy ◽

Left Ventricular ◽

Left Ventricular Lead ◽

Epicardial Lead ◽

Lead Placement ◽

Ventricular Lead ◽

Cardiac Resynchronisation ◽

Resynchronisation Therapy ◽

Left Ventricular Lead Placement

Left ventricular (LV) lead in cardiac resynchronisation therapy (CRT) is the most important and difficult lead to place, leading to abandonment of up to 10–15 % of procedures. Here we discuss various difficulties encountered in percutaneous placement of LV leads and what all can be done to ensure successful placement of the same and to prevent the already compromised patient from the requirement of epicardial lead placement.

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Robotic-Assisted or Minithoracotomy Incision for Left Ventricular Lead Placement a Single-Surgeon, Single-Center Experience

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e31826153b3 ◽

2012 ◽

Vol 7 (3) ◽

pp. 208-212 ◽

Cited By ~ 6

Author(s):

Castigliano Murthy Bhamidipati ◽

Igor W. Mboumi ◽

Keri A. Seymour ◽

Roberta Rolland ◽

Karikehalli Dilip ◽

...

Keyword(s):

Minimally Invasive ◽

Patient Characteristics ◽

Left Ventricular ◽

Tactile Feedback ◽

Pacing Threshold ◽

Robotic Assisted ◽

Single Center Experience ◽

Epicardial Lead ◽

Lead Placement ◽

Ventricular Lead

Objective Left ventricular (LV) resynchronization with epicardial lead placement after failed coronary sinus cannulation can be achieved with minimally invasive robotic-assisted (RA) or minithoracotomy (MT) incisions. We evaluated early outcomes and costs after RA and MT epicardial LV lead implantation at our academic center. Methods From 2005 to 2010, 24 patients underwent minimally invasive RA or MT epicardial LV lead placement for resynchronization. Patient characteristics, electrophysiologic features, outcomes, and costs were analyzed. Results Ten patients underwent RA and 14 underwent MT minimally invasive LV lead placement, with no 30-day mortality in either group. Younger patients underwent RA epicardial lead placement (63.8 ± 15.4 vs 75.6 ± 10.0 years; P = 0.03). In addition, although both groups had comparable body surface areas, RA patients had significantly higher body mass index versus MT patients (44.4 ± 17.5 vs 26.9 ± 7.1 kg/m2, respectively; P = 0.003). Premorbid risk and cardiovascular profiles were similar across groups. Importantly, pacing threshold, impedance, and postoperative QRS interval were equivalent between groups. Significantly, both operating room and mechanical ventilation durations were higher with RA epicardial placement (P < 0.001). Despite equivalent outcomes, incision-to-closure interval was 48 minutes shorter with MT (P = 0.002). Absolute differences in direct costs between groups were negligible. Despite these differences, resource utilization and lengths of stay were equivalent. Conclusions Epicardial LV lead placement is efficacious with either approach. Early outcomes and mortality are equivalent. Greater tactile feedback during operation and equivalent short-term outcomes suggest that MT minimally invasive LV lead placement is the more favorable approach for epicardial resynchronization.

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Abstract 12776: Long Term Mortality With Right Ventricular Apical Versus Septal Pacing

Circulation ◽

10.1161/circ.132.suppl_3.12776 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Chance M Witt ◽

Charles J Lenz ◽

Henry H Shih ◽

Elisa Ebrille ◽

Andrew N Rosenbaum ◽

...

Keyword(s):

Right Ventricular ◽

Pacemaker Implantation ◽

Dual Chamber ◽

Dual Chamber Pacemaker ◽

Lead Position ◽

Ventricular Lead ◽

Significant Difference ◽

Long Term Mortality

Introduction: Right ventricular apical (RVA) pacing appears to have detrimental effects on cardiac function and long term outcomes. Right ventricular non-apical (RVNA) pacing, especially in the septal position, has been postulated as an alternative that may lead to less morbidity and mortality. Prior studies have shown conflicting results and been limited by small numbers and short follow-up. We aimed to determine if right ventricular septal lead position was associated with a reduction in long-term mortality compared to RVA lead position. Methods: Patients who underwent dual-chamber pacemaker implantation from 2004 through 2013 were evaluated for right ventricular lead position based on chest radiographs. Lead positions were divided in to apical or non-apical. Non-apical lead positions were subdivided to isolate a septal lead position group. Mortality was compared between these groups. Results: During the study period, 3456 patients underwent dual-chamber pacemaker placement and had images appropriate for lead position evaluation. The group was 53.5% male with a mean age of 74 ± 13 years. RVNA lead position was found in 976 (28.2%) patients, including 243 (7.0%) with a septal position. There was no significant difference in age or prior heart failure diagnosis between groups. Kaplan-Meier survival analysis did not reveal a significant difference in mortality between patients with RVA versus RVNA lead position during 5 year follow-up (p = 0.82). However, septal lead position was associated with a significantly lower mortality compared with RVA position (p = 0.03) (figure). Conclusions: Right ventricular septal lead position is associated with a lower long-term mortality than RVA lead position. This has substantial implications regarding the preferred site for ventricular pacing lead placement.

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Transesophageal Echocardiography–Guided Epicardial Left Ventricular Lead Placement by Video-Assisted Thoracoscopic Surgery in Nonresponders to Biventricular Pacing and Previous Chest Surgery

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000508 ◽

2018 ◽

Vol 13 (3) ◽

pp. 211-217 ◽

Cited By ~ 1

Author(s):

Carsten Schroeder ◽

Jane M. Chung ◽

Judith A. Mackall ◽

Ivan T. Cakulev ◽

Aaron Patel ◽

...

Keyword(s):

Transesophageal Echocardiography ◽

Thoracoscopic Surgery ◽

Biventricular Pacing ◽

Left Ventricular ◽

Left Ventricular Lead ◽

Video Assisted ◽

Lead Placement ◽

Ventricular Lead ◽

Left Ventricular Lead Placement ◽

Video Assisted Thoracoscopic Surgery

Objective The aim of the study was to study the feasibility, safety, and efficacy of transesophageal echocardiography–guided intraoperative left ventricular lead placement via a video-assisted thoracoscopic surgery approach in patients with failed conventional biventricular pacing. Methods Twelve patients who could not have the left ventricular lead placed conventionally underwent epicardial left ventricular lead placement by video-assisted thoracoscopic surgery. Eight patients had previous chest surgery (66%). Operative positioning was a modified far lateral supine exposure with 30-degree bed tilt, allowing for groin and sternal access. To determine the optimal left ventricular location for lead placement, the left ventricular surface was divided arbitrarily into nine segments. These segments were transpericardially paced using a handheld malleable pacing probe identifying the optimal site verified by transesophageal echocardiography. The pacing leads were screwed into position via a limited pericardiotomy. Results The video-assisted thoracoscopic surgery approach was successful in all patients. Biventricular pacing was achieved in all patients and all reported symptomatic benefit with reduction in New York Heart Association class from III to I–II ( P = 0.016). Baseline ejection fraction was 23 ± 3%; within 1-year follow-up, the ejection fraction increased to 32 ± 10% ( P = 0.05). The mean follow-up was 566 days. The median length of hospital stay was 7 days with chest tube removal between postoperative days 2 and 5. Conclusions In patients who are nonresponders to conventional biventricular pacing, intraoperative left ventricular lead placement using anatomical and functional characteristics via a video-assisted thoracoscopic surgery approach is effective in improving heart failure symptoms. This optimized left ventricular lead placement is feasible and safe. Previous chest surgery is no longer an exclusion criterion for a video-assisted thoracoscopic surgery approach.

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