Comparison of the Efficacy of Two Surgical Alternatives for Cardiac Resynchronization Therapy: Trans-Apical versus Epicardial Left Ventricular Pacing

Abstract

Epicardial pacing lead implantation is the currently preferred surgical alternative for left ventricular (LV) lead placement. For endocardial LV pacing, we developed a fundamentally new surgical method. The trans-apical lead implantation is a minimally invasive technique that provides access to any LV segments. The aim of this prospective randomized study was to compare the outcome of patients undergoing either trans-apical endocardial or epicardial LV pacing. In group I, 11 end-stage heart failure (HF) patients (mean age 59.7 ± 7.9 years) underwent trans-apical LV lead implantation. Epicardial LV leads were implanted in 12 end-stage HF patients (group II; mean age 62.8 ± 7.3 years). Medical therapy was optimized in all patients. The following parameters were compared during an 18-month follow-up period: LV ejection fraction (LVEF), LV end-diastolic diameter (LVEDD), LV end-systolic diameter, and New York Heart Association (NYHA) functional class. Nine out of 11 patients responded favorably to the treatment in group I (LVEF 39.7 ± 12.5 vs 26.0 ± 7.8%, P < 0.01; LVEDD 70.4 ± 13.6 mm vs 73.7 ± 10.5 mm, P = 0.002; NYHA class 2.2 ± 0.4 vs 3.5 ± 0.4, P < 0.01) and eight out of 12 in group II (LVEF 31.5 ± 11.5 vs 26.4 ± 8.9%, P = < 0.001; NYHA class 2.7 ± 0.4 vs 3.6 ± 0.4, P < 0.05). During the follow-up period, one patient died in group I and three in group II. There was one intraoperative LV lead dislocation in group I and one early postoperative dislocation in each group. None of the patients developed thromboembolic complications. Our data suggest that trans-apical endocardial LV lead implantation is an alternative to epicardial LV pacing.