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Particular Situations in CardiacResynchronisation
Alexander BreitensteinArrhythmia Unit, Cardiology, University Hospital Zurich
Devdas Th. Inderbitzin
Cardiac Surgery, University Hospital Zurich
Potential conflicts of interest
PD Dr. A. Breitenstein:
• Consulting fees from BMS/Pfizer and Bayer Health Care
• Educational grants from Biosense Webster, Biotronik andActelion
• Presenter fees from BMS/Pfizer and Medtronic
Dr. D. Th. Inderbitzin:
• Received educational grant from St. Jude Medical
Heart Failure -Treatment beyond medication
Implantable cardioverterdefibrillator (ICD)
Protection from suddencardiac death
Cardiac resynchronisationtherapy (CRT)
Improvement of heart function
Artificial hearts & transplantation
Replacement of heartfunction or heart (HTX)
Ponikowski et al. EHJ 2016; 37: 2129-2200
ESC Guidelines 2015 - Indications for CRT
Implantation Strategies for CRT
1. Percutaneous transvenous CRT implantation
2. Percutaneous transseptal CRT implantation
3. Epicardial LV lead implantation• Fully epicardial system
• Mixed epicardial - transvenous system
4. Transapical LV lead implantation
Percutaneous transvenous CRT implantation
Percutaneous transvenous CRT implantation
Percutaneous transvenous CRT implantation
Percutaneous transseptal CRT implantation
Calvo et al. Europace 2014; 16: 1857-1859
RV
lead
RV
leadLV leadLV leadTransseptal access
Transseptal access
Epicardial Lead Implantation
Indications:
• Failure of transvenous implant
• Transvenous device-related infection
• Concomitant AV block and cardiac surgery
• Mostly used for LV lead in CRT upgrading
Epicardial Lead Implantation
• Surgical lead implant
• Access: left thoracic approach - Sternotomy (for full epicardial system)- Subxyphoid access (RV)- Thoracoscopic (for LV lead)- Posterolateral thoracotomy (4.ICR)
• Lead examples: - epicardial button (CapSure Epi)- screwed-in active leads (MyoDexTM)
Navia J.L. et al. Ann Thor Surg 2005;80(2):751–54
Epicardial LV (LA) Lead Implantation –Thoracotomy
Posterolateralminithoracotomy
Cave: Coronaryvessels!
Epicardial activeelectrode on LV
Connection of theleads to generator
Coronary sinus leadwith phrenic nerve stimulation
Inderbitzin DT et al. Forum Med Suisse 2011 ;11(10):179–180Navia J.L. et al. Ann Thor Surg 2005;80(2):751–54
Epicardial LV Lead Implantation –Thoracoscopy
Epicardial LV lead implantation –Thoracoscopy
Epicardial implant ofactive electrode
Inderbitzin DT et al. Forum Med Suisse 2011 ;11(10):179–180
Epicardial LV Lead Implantation
Atrial lead
RV lead
LV leadAtrial lead
RV lead
LV lead
• Post-Implant MyoDex • Dislocation of MyoDex
Indications:
• Multiple lead dislocations
• Failure of transvenous approach (no CS route)
• Non-responder
• Pericardial adhesions (redo after complex heart- or lung surgery)
Aim:
Simple, fast direct access to the LV
Transapical Endocardial LV Lead Implantation
Surgical Technique:
• Left anterior mini-thoracotomy
• Pericardiotomy, plegdgetedpursestring on apex
• Puncture of apex (Seldinger)
• Intracardial navigation and endocardial fixation of the electrode (under fluoroscopy)
• Subcutaneous tunneling of to the generator
Transapical Endocardial LV Lead Implantation
RA lead
RV lead
LV lead
RA lead
RV lead
LV lead
Transapical Endocardial LV Lead Implantation
Epicardial CRT with ICD Function ?
Conclusions
• Large armamentarium available:from transvenous to epicardial surgical approach
• Careful patient evaluation
• Stepwise selection of optimal implantation mode
• Importance of competent Arrhythmia Heart-Team
• Interdisciplinary procedure in hybrid OR
Thank you for your kind attention!