Video-assisted pericardioscopic surgery: refinement of a new technique for implanting epimyocardial pacemaker leads.

Objective: Current alternative approaches for pacemaker lead implantation imply the breach of the pleural space. Recently, the feasibility of experimental lead implantation by rigid endoscopy has been described. The use of flexible endoscopes and a standardised application has not been realised yet. Our main goal was to compare rigid and flexible endoscopy and to establish a standardised protocol for the implementation of a closed-chest subxiphoid approach for epimyocardial lead implantation.

Methods: Rigid and flexible endoscopes were used for placement of screw-in pacing leads (4-F). A total of 17 adult pigs (80 kg) were anaesthetised and a 10-mm subxiphoid axial incision performed. The pericardium was opened and entered under endoscopic vision. Epimyocardial electrodes were implanted through the endoscope onto all four chambers. Standard haemodynamic measurements and pacing measurements were carried out.

Results: Both methods were deployed in the first three individuals. Superior endorsement of rigid endoscopy, due to better orientation and stability, led to its exclusive deployment in the remaining 14 individuals. Access to the implantation sites was quick (<10 min). A plastic cover had to be applied to reduce arrhythmia (VentricularExtraSystoles(bare): 17 ± 2.2 min(-1) vs VentricularExtraSystoles(cover): 5 ± 1.9 min(-1); n = 4). Measured pacing parameters were comparable with classic endocardial-derived thresholds. Post-mortem examination revealed no relevant damage/injury and/or bleeding in the heart and circumjacent tissue. There was no evidence of injury at the implantation sites and the corresponding pericardium. The electrodes showed excellent anchorage inside the myocardial tissue (penetration depths: 3 ± 0.2mm) and resisted high tractive forces.

Conclusion: Flexible endoscopy is not suitable for exclusive deployment inside the pericardial space, whereas rigid endoscopy presented itself as a safe, fast and simple approach for epimyocardial lead implantation using an insulating trocar. Without cover, malignant arrhythmia constrains the implementation of video-assisted pericardioscopic surgery (VAPS). Subxiphoid VAPS permits optimal lead positioning under direct vision without fluoroscopy, without the breach of the pleural space and with a short procedural duration (<60 min). Our standardised minimal-invasive approach allows visualisation and intervention, potentially of all intrapericardial structures.