Cardiac resynchronization therapy with an implantable cardiac defibrillator: which procedure of the left ventricular lead placement is more suitable for the patient?

Abstract

Background Cardiac resynchronization therapy (CRT) is an established therapy. There are two techniques to implant the left ventricular (LV) lead i.e. transvenous implantation (TI) via the coronary sinus and surgical implantation using left lateral minithoracotomy (LLM). This study was designed to compare the procedures, treatment results as well as complications. Methods In this study we included 81 patients (pat.). All pat. received right atrial and ventricular lead using established TI techniques. The LV lead was positioned via the coronary sinus (59 pat.) or via LLM epimyocardially (22 pat.). Baseline evaluation included assessment of NYHA functional class, electrocardiogram and echocardiography. These measurements were repeated during the follow-ups (FU). Additionally data on the procedure as well as perioperative data was collected. Results Both groups showed significant improvement in NYHA (3,2±0,4 to 2,0±0,6, p<0,001) as well as in the LV-ejection fraction by 22 percent (p<0,001). The TI group had an average implantation time of 134±46,8 minutes. Pat. with LLM had an average operation time of 116,6±48,7 minutes. Intensive care unit (ICU) treatment after implantation were 1,3±1,6 days (TI) versus 3,4±3 days in the epimyocardial group (p<0,001). Postoperative stay was significantly longer in the epimyocardial group (9,4±6,4 days) compared to 6,1±3,1 days (p<0.001) (TI). No deaths occurred intra- or perioperative in the hospital. No significant differences were found during further FU. Conclusion The transvenous positioning of the lead does have prolonged procedure time, longer x-ray time and higher incidence of reinterventions due to lead dislocations compaired to epimyocardial implantation. However, the results of this study suggest that pat. who are eligible for CRT should receive their LV lead as a primary procedure transvenously due to less trauma, local anesthesia, less ICU treatment, less days in hospital and consequentially lower costs for an implantation. To receive comparatively results a prospective randomized study is necessary.