Minithoracotomy as the primary alternative for left ventricular lead implantation during cardiac resynchronization therapy: Can the cardiac surgeon reduce the number of nonresponders

Introduction/Objective. Numerous anomalies of the cardiac venous system prevent the optimal endovascular implantation of the left ventricular (LV) lead in more than 15% of patients with indication for cardiac resynchronization therapy (CRT). The endovenous approach in these patients can be one of the potential reasons for the large number of nonresponders reported in the literature. The purpose of this study was to analyze the results of an alternative myoepicardial approach to the stimulation of the left ventricle in CRT. Methods. From June 2014 to December 2015 at the Department of Cardiac Surgery of the Clinical Centre of Serbia, 15 myoepicardial LV leads for CRT were implanted. Coronary sinus venography revealed thrombosis of the coronary sinus in nine patients, and unfavorable anatomy of the coronary venous system in six patients. In all patients, limited left thoracotomy was used as an approach to the lateral wall of the heart. Results. There were no major surgical complications and no lethal hospital outcomes. In a six-month follow-up period we registered a significant increase in the length of the six-minute walk test (for an average of 57.9 m), reduction of the QRS complex width (to 26.25 ms), increase in left ventricular ejection fraction (12.2%), and reduction of mitral regurgitation for 1+. Based on all the parameters, it was concluded that all patients responded favorably to the applied CRT. Conclusion. Closer cooperation between cardiologists and cardiac surgeons in identifying patients who would benefit the most from a myoepicardial approach for LV stimulation is necessary in order to attempt to reduce the nonresponder rate.