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Eur J Cardiothorac Surg 2005;28:184-185
© 2005 Elsevier Science NL
Letter to the Editor |
a Department of Cardiac Surgery, University Hospital, 15706 Santiago de Compostela, Spain
b Department of Cardiology, University Hospital, 15706 Santiago de Compostela. Spain
c Department of Anesthesiology, University Hospital, 15706 Santiago de Compostela, Spain
Received 7 March 2005; accepted 22 March 2005.
* Corresponding author. Tel.: +34 981 0950 212; fax: +34 981 950 227. (Email: alfg{at}secardiologia.es).
Key Words: Cardiac resynchronization therapy • Surgically placed epicardial LV-lead • Heart failure
We read with great interest the article by Mair and colleages [1] which compared the surgical implantation of left ventricular epicardial leads with the coronary sinus placement for cardiac resynchronization.
We have previously reported our experience [2] with surgical implantation of left ventricular epicardial leads using video-assisted thoracoscopy and agree with Mair et al. that the surgical approach may have potential benefits as primary implantation for a substantial subset of patients. However, we would like to point out some considerations.
First, we believe that preoperative patient selection plays a critical role in order to identify nonresponders to cardiac resynchronization therapy. Standard criteria such as QRS duration, depressed left ventricular ejection fraction and heart failure have been used in large randomized trials [3]. Nevertheless, these standard criteria should be complemented with Doppler-echocardiographic demonstration of intraventricular asynchrony and the evaluation of the hemodynamic changes during left ventricular stimulation. Our protocol includes tissue Doppler imaging to determine the sequence of ventricular wall contraction in a similar way as described by Mair et al. [1]. In addition we routinely perform endocardial pacing of different segments of the left ventricle during the preoperative cardiac catheterization to evaluate changes on dP/dt, cardiac output and pulmonary arterial pressure [4].
Second, we prefer video-assisted thoracoscopy instead of minithoracotomy because it is a less invasive technique although the presence of pleural or pericardial adhesions can hinder the procedure and even force conversion from thoracoscopy to minithoracotomy. We routinely use orotracheal intubation with a double lumen tube for selective pulmonary ventilation. This technique allows the collapse of the left lung, facilitates the vision of the pericardium and avoids laceration of the lung and pneumothorax. In our series of 19 consecutive patients we have not observed hemodynamic or ventilation complications during the collapase of the left lung although it required expert anesthetic management. All our patients have been extubated in the operating room. Convalescence has been satisfactory without complications unless an episode of postoperative atrial fibrillation.
Finally, we have observed acute and chronic left ventricular pacing thresholds similar to those in the Mair et al. study [1] which are significantly lower to the coronary sinus leads.
From our point of view, the article of Mair et al. [1] as well as other reports [5] have demonstrated that surgical epicardial implantation of left ventricular leads—either with minithoracotomy, video-assisted or robotic-assisted [1,2,5]—is more reliable than the percutaneous coronary sinus approach, allows the best possible lead position and therefore should be considered the technique of choice for left ventricular pacing in cardiac resynchronization.
References
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