Thoracoscopic Left Ventricular Lead Implantation in Cardiac Resynchronization Therapy
A 49-yr-old woman with dilated cardiomyopathy was transferred to our hospital from a local hospital because of heart failure (NYHA functional class IV) on 27 July 2011. She had a history of DDD pacemaker insertion for a complete atrioventricular block 2 yr previously.\nOn echocardiography, the LVEF was 17% with global hypokinesia. The LV end diastolic dimension was 78 mm. No regional wall motion abnormality was found. The severity of mitral regurgitation was mild to moderate, and the other valves were normal. The right ventricle was dyssynchronous. On an electrocardiogram the QRS duration was increased to 240 ms.\nThe first attempt at implantation of a CRT defibrillator (ProtectaXT; Medtronic, Minneapolis, MN, USA) was performed using the intravenous approach. The atrial lead and right ventricular lead were implanted without problems; however, LV lead insertion failed because of very small cardiac veins. The generator was positioned in the left subclavicular pocket, and the pacemaker leads except the LV lead were connected. The pocket was closed, and epicardial LV lead insertion via VATS was planned.\nThe operation was performed under general anesthesia using a double lumen tube for unilateral lung ventilation. The patient was placed in the right lateral decubitus position with sufficient posterior tilt. The left arm was draped and positioned over the patient's head to allow easy access to the pacemaker within the sterile field. The subclavicular pocket for the generator was reopened before one-lung ventilation.\nAfter one-lung ventilation, a 2-cm incision for a 15-mm port was made in the sixth intercostal space at the posterior axillary line. A 30° thoracoscope was inserted for inspection of the thoracic cavity. Two additional 5-mm ports were positioned in the fourth intercostal space anterior to the anterior axillary line (second port) and mid-axillary level (third port). The thoracoscope was moved to the third port.\nA 2-cm pericardiotomy was performed anterior to the phrenic nerve to expose the lateral wall of the left ventricle. A screw-in bipolar lead was implanted via the 15-mm port into an area of the myocardium that had been targeted on preoperative chest computed tomography. The proximal end was directed toward the cephalad. After threshold measurements, the proximal end of the lead was tunneled up to the subclavicular pocket and connected to the generator. A 20-cm loop of the lead was loosely placed in the thoracic cavity to facilitate re-expansion of the lung without exerting traction to the lead. A chest tube was inserted through the mid-axillary (third) port and guided cranially under thoracoscopic vision. After completion of the operation, the position of the LV lead was verified by chest X-ray ().\nThe threshold and impedance were 1.0/0.4 ms and 361 Ω, respectively. The QRS duration changed from 240 ms preoperatively to 156 ms postoperatively (). After a follow-up of 3 months, LVEF had improved to 30%, and LV end diastolic dimension had decreased to 69 mm. NYHA functional class was II.