Epicardial lead placement

A 63-year-old federal court judge, with no prior arrhythmia or syncope history, requires a biventricular ICD for Class Iff CHF, with the left ventricular lead via an epicardial route. He wishes only initially to have the basic ICD implant, after which he will clear his schedule and return for the epicardial lead. Two weeks prior to the scheduled epicardial lead placement you are called to interrogate his ICD in a local ER trauma ward. Apparently while driving, the patient passed out and struck a tree, amazingly without significant injury. His potassium is found to be 2.1 mEq/dL. The EGMs leading to an appropriate successful shock are seen below. 

Pacing leads can be subdivided into a number of groups based on the area of placement and method of stimolation. Leads can be placed either on the epicardium (external surface) of the heart or, by a transvenous route, onto the endocardium (internal surface) of the right heart atrium or ventricle. Epicardial leads are used for permanent pacing in pediatric cases, where size considerations or congmtal defects prevent transvenous placement, and in patients who have undergone tricuspid valve rqilacement (Mitrani et al., 1999). Transvenous placement of the lead is the preferred route in most patients. 

Recently, thoracoscopic approaches, less risky than thoracotomy, have been developed for the placement of left ventricnlar leads (155-157). Still to be resolved are the issues of lead instabihty and unreliable sensing and pacing characteristics. On the horizon, with respect to an epicardial approach, is a percntaneons technique utilizing robotics for left-sided lead placement. 

Dekker AL, Phelps B, Dijkman B, van der Nagel T, van der Veen FH, Geskes GG, Maessen JG. Epicardial left ventricular lead placement for cardiac resynchronization therapy optimal pace site selection with pressure-volume loops. J Thorac Cardiovasc Surg 2004 127 1641-7. 

Successful placement of the LV lead in the target vein has been aided by continuing improvements in the available delivery tools as well as individual operator experience. In CONTAK CD (performed from 1998 to 2000), 79% of attempted implants resulted in successful transvenous implant of the LV lead. In COMPANION (2000 to 2002), the success rate was 89%, with median procedure duration of 2.8 hours. And in CARE-HF (2001-2003), the success rate was 95% (86% on first attempt). Patients who fail to undergo successful transvenous implantation of the LV lead into an optimal target vein have the option to undergo limited thoracotomy for direct implantation of an epicardial LV lead. 

The personnel required for insertion of an ICD are very similar to those of the pacemaker implantation. The ICD manufacturer s representative, however, as stated, is controversial. He or she can be an important member of the implantation team and can prove invaluable for providing leads, defibrillators, and support equipment. The earlier ICD implantations that were limited to epicardial placement required a minimum of two trained physicians (an electrophysiologist and a cardiac surgeon). With the transition to the nonthoracotomy approach, a well-trained electrophysiologist working with an ICD manufacturer s representative is frequently all that is required. The ideal constitution of an ICD implantation team is listed in Table 4.1. Each member of the ICD implant team should be completely familiar with the unique requirements of an ICD implantation. This includes a protocol for patient rescue, should it be required. The circulating nurse is responsible for running... 

Shonld a complete obstrnction between the superior vena cava and right atrium be documented, it is likely that the only reasonable approach for pacing will be an epicardial system, although there is at least one report of the use of the transhepatic approach for placement of a permanent pacing lead in such a patient (43). However, if there is stenosis without complete obstruction, one may consider balloon dilation with or without placement of an expandable stent (44). If a stent is placed, one should not cross the site immediately with a pacemaker lead becanse of the chance of dislodging the stent. If a stent is not placed, one shonld still wait nntil the area has healed to avoid the possibility of disrnpting an area with a fresh intimal tear. 

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