Implantation of left ventricular epicardial leads in cardiosurgical patients with impaired cardiac function--a worthwhile procedure in concomitant surgical interventions?

Background: Cardiac resynchronization therapy (CRT) by means of multisite biventricular pacing is an effective therapeutic option for the treatment of severe heart failure. The present study estimates how many open heart-surgery patients could benefit from the implantation of permanent left ventricular (LV) pacing leads. After routine preoperative screening, epicardial electrodes were implanted in selected patients. Lead performance and outcomes were investigated.

Methods: Primarily, 1059 patients were retrospectively investigated with regard to LV function, left bundle branch block and QRS duration. Afterwards, suitable patients were identified and epicardial electrodes [Medtronic 5071 (ME) or Enpath (EP)] were implanted during concomitant procedures. Mean follow-up time was 6.3 ± 5.5 months.

Results: The retrospective study showed that 24 patients (2.3%) could potentially profit from CRT. After routine preoperative screening for CRT-responders, 22 patients (1.6%) were identified who finally received epicardial leads. No complications occurred. Acute capture threshold was 0.9 ± 0.4 V (ME, n = 17) and 0.5 ± 0.2 V (EP, n = 5). While leads in 18 patients were implanted as an upgrade to an existing pacemaker or implantable cardioverter-defibrillator (ICD) technologies (Group B), 4 patients underwent prophylactic implantation with no device attached (Group A). CRT-ICDs were implanted at follow-up in 3 Group A patients (75%). In Group B patients, the QRS duration decreased (from 189 ± 35 ms to 152 ± 16 ms, p < 0.02) and their postoperative mean NYHA functional class improved significantly (2.2 ± 0.5 versus 2.8 ± 0.6).

Conclusion: A small group of cardiac surgery patients may benefit from LV-lead implantation during concomitant procedures. A protocol for responder identification is useful. Existing devices should be upgraded to CRT systems. As CRT-ICD implantation is frequent, the additional costs and time are justified.