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J Thorac Cardiovasc Surg 2001;122:491-492
© 2001 The American Association for Thoracic Surgery
Evolving Technology (ET) |
From the Department of Thoracic and Cardiovascular Surgery, Georg-August University, Göttingen, Germany.
Received for publication Nov 28, 2000. Accepted for publication Jan 29, 2001. Address for reprints: Horia Sirbu, MD, FETCS, Klinik für Thorax-, Herz- und Gefäßchirurgie, Georg-August-Universität Göttingen, Robert Koch Straße 40, D-37075 Göttingen, Germany (E-mail: hsirbu{at}gwdg.de).
Transvenous implantation of endocardial ventricular and atrial pacing leads is today the method of choice in adults. It is a well-tolerated procedure and generally performed under fluoroscopic control with local anesthesia.
1 Video-assisted thoracic surgery (VATS) is a well-established procedure with many indications in general thoracic and cardiac surgery. 1-3 Recent advances and improvements in surgical techniques, devices, and video equipment have expanded the possibilities and allowed endoscopic performance of more complex procedures. In complex cases, epicardial lead insertion via an anterolateral thoracotomy or a subxiphoid approach is often required. 1,4 VATS presents an interesting option in these patients to avoid more extensive surgical procedures.
In this report we describe our first successful experience with a VATS-guided transthoracic implantation of a double-chamber pacemaker (DDDR-mode) in a patient with bilateral subclavian venous thrombosis.
Clinical summary
A 66-year-old man was referred to our cardiac and thoracic surgical department with a history of syncope, intermittent third-degree atrioventricular block, chronic renal insufficiency, and bilateral subclavian venous thrombosis resulting from many years of hemodialysis. Two years earlier the patient received a renal transplant and since then he received immunosuppressive therapy (cyclosporine [INN: ciclosporin] and prednisone). Clinical examination revealed enlargement of the superficial veins of the upper part of the thorax as a consequence of cavo-caval anastomosis and bilateral deltopectoral surgical scars after multiple failed attempts at pacemaker implantation. Doppler examination and magnetic resonance imaging phlebography showed bilateral subclavian venous obstruction with cavo-caval anastomosis and dye refilling of the superior vena cava at the azygos vein confluence. After obtaining written informed consent from the patient, we performed the VATS operation.
The patient was placed in the left lateral decubitus position with general anesthesia and left-sided double-lumen endotracheal intubation, which allowed selective blockage of the right lung and one-lung ventilation. A small right-sided lateral incision was performed in the seventh intercostal space at the posterior axillary line and a 10-mm rigid trocar sleeve was advanced intrathoracically. This Port-Access method (Heartport, Inc, Redwood City, Calif) was used for introduction of a 45° thoracoscope (Olympus Optical Co, Ltd, Tokyo, Japan). A second 2.5-cm incision was performed in the sixth intercostal space at the anterior axillary line, and one additional trocar was inserted under thoracoscopic vision. This larger port was used for introduction of endoscopic clamps, forceps, and a needle holder(Figure 1). The endoscopic picture was transmitted to one screen system (Olympus OTV-S6) situated at one side of the patient.
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The bipolar, atrial, steroid-eluting lead (Medtronic CapSure Fix 5076) was introduced 2 cm from the first lead by the same technique in the superior vena cava. After several lead repositionings, a proper place was found in the right atrial lateral wall. Under fluoroscopic control, the electrode helix was rotated into the atrial endocardium. The atrial lead was fixed, and function control was measured in an analogous fashion with the ventricular lead. Both leads were connected with a dual-chamber pacemaker (Discovery DR-1274; Guidant Corporation, Indianapolis, Ind), which was placed extrathoracically in the subcutaneous tissue at the level of the anterior port incision. For passage of the battery subcutaneously, the port incision had to be enlarged by 1.5 cm. One chest tube (20F) was introduced through the posterior trocar sleeve and connected to a suction drainage device. The port incision was closed in two layers. The operating time was 110 minutes. The patient was extubated in the operating room. No analgesic drugs were necessary during the postoperative course. The tube drainage was removed on the first postoperative day and the patient was discharged to his home in very good condition on the fifth postoperative day.
Discussion
Since its introduction in the early 1990s, VATS has been proposed to be a less invasive approach with an improved postoperative course and less pain than open procedures. Several reports have described the validity of these improvements and the advantages of VATS for the treatment of thoracic and cardiac disease. 1,2 In patients with complex disease who need pacemaker implantation, extensive surgical approaches with anterior thoracotomy, subxiphoid laparotomy, or sternotomy for pacemaker or defibrillator epicardial lead implantation have been performed. 5 It seems to be logical in such cases to try a less extensive surgical technique like VATS-guided endocardial pacemaker implantation.
A MEDLINE search of the medical literature since 1966 revealed no report associating VATS technique with endocardial pacemaker lead implantation. In the past, several attempts have been made to minimize surgical trauma by means of pericardioscopy or thoracoscopy for implanting cardioverter-defibrillator epicardial patches or to place monopolar sutureless screw-in or hook leads. 3,4 In a single report, VATS-guided epicardial lead implantation was performed in a group of 10 animals. 1
In the present case, we noticed problems with the standard positioning of the atrial lead in the right appendage because of the 90° insertion lead angle in the superior vena cava (Figure 2). Therefore, the helix of the atrial lead was positioned near the opening of the inferior vena cava in the right atrium. Additionally, the fact that this case was our first attempt with this technique may explain the relatively long operative time.
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References
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