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!