Commentary: Thoracoscopic epicardial permanent pacemaker lead placement: An alternative not a substitute

Central MessageThoracoscopic placement of epicardial permanent pacemaker leads represents an alternative to traditional surgical options. The challenges are mostly related to previous median sternotomy.See Article page 245. Thoracoscopic placement of epicardial permanent pacemaker leads represents an alternative to traditional surgical options. The challenges are mostly related to previous median sternotomy. See Article page 245. Transvenous placement of permanent pacemaker leads has been established as a reliable and less invasive approach for permanent pacing. However, this technique might not be suitable or possible for every patient. Those with systemic venous anomalies, functional single ventricle, and small infants/children are better served with epicardial systems. Several approaches have been described for placement of epicardial pacing leads (EPLs). Thoracotomy (right/left, anterior/lateral), subcostal,1Warner K.G. Halpin D.P. Berul C.I. Payne D.D. Placement of a permanent epicardial pacemaker in children using a subcostal approach.Ann Thorac Surg. 1999; 68: 173-175Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar and subxiphoid2Stewart S. Placement of the sutureless epicardial pacemaker lead by the subxiphoid approach.Ann Thorac Surg. 1974; 18: 308-313Abstract Full Text PDF PubMed Scopus (13) Google Scholar approaches are common examples that have been tailored based on patient body habitus and anatomy and the leads required. The concerns associated with the epicardial system include a higher incidence of lead failure and less durability compared with the endocardial system.3McLeod C.J. Attenhofer Jost C.H. Warnes C.A. Hodge II, D. Hyberger L. Connolly H.M. et al.Epicardial versus endocardial permanent pacing in adults with congenital heart disease.J Interv Card Electrophysiol. 2010; 28: 235-243Crossref PubMed Scopus (51) Google Scholar It represents a challenge when placement is required for those who underwent previous sternotomy, in whom difficulty often arises from trying to identify the optimal epicardial location to place the lead and when navigating through the epicardial scars. In fact, it is not uncommon to go through several attempts of securing the lead, testing, and then relocating it to confirm a good impedance and threshold. Sometimes “screw-in” leads are used, although these are less preferred compared with the “steroid-eluting” leads in some of these challenging scenarios. Nellis and colleagues4Nellis J.R. Alsarraj M.K. Sauer J.S. Klapper J.A. Idriss S.F. Turek J.W. A minimally invasive approach for atrial and ventricular sew-on epicardial lead placement.J Thorac Cardiovasc Surg Tech. 2021; 7: 245-248Scopus (3) Google Scholar described the use of video-assisted thoracoscopy (VATS) for placing “sew-on” EPLs in 5 children. The procedure was feasible in 4 patients and was converted to a mini-thoracotomy in 1 patient with hypoplastic left heart syndrome due to dense adhesions. The authors used the commercially available RAM device to place the leads, which were further secured using Cor-Knot titanium fastening devices. The use of VATS to place EPLs has been described previously.5Schaeffer T. Mork C. Erb J. Reuthebuch O. Thoracoscopic epicardial left ventricular bipolar lead implantation with the use of automated titanium fasteners (Cor-Knot).J Cardiothorac Surg. 2019; 14: 121Crossref PubMed Scopus (1) Google Scholar However, it is worth discussing the following points:1.The applicability of this technique in congenital patients with multiple previous sternotomies remains to be determined. This is not only due to the dense mediastinal adhesions that are not infrequently encountered (one patient in the current series), but also because the procedure assumes that the optimal sites of the EPLs are identified from the first encounter. Securing the lead with the Cor-Knot device and realizing that the threshold/impedance is not satisfactory (high in the current series) will require relocating the lead to a different spot, which might not be easily achievable with the current technique of lead securement.2.Patients with functional single ventricle may represent a challenge to this approach. The adhesions from previous sternotomies and the need for isolated lung ventilation for VATS may add unnecessary risk in these patients with suboptimal hemodynamics.3.The provided length of stay seems to be longer than would be expected for a minimally invasive approach.4.What is the optimal type of suture to use for the atrial/ventricular leads? These sutures need be compatible with the Cor-Knot device as well and less problematic when placed through the thin atrial wall/fragile myocardium.5.Like any other approach, patient selection is key, and identifying the right patient for VATS placement of EPLs is critical to its success. Finally, I congratulate the authors on their approach, which seems to be a good option for the right patients. Nonetheless, I believe it will be important to compare the outcomes of the current approach with other techniques available for EPL placement to determine the feasibility, effectiveness, and practicality of such approach. A minimally invasive approach for atrial and ventricular sew-on epicardial lead placementJTCVS TechniquesVol. 7PreviewPermanent pacemaker (PPM) placement in pediatric patients is rare. Indications for permanent pacing in children include congenital and postsurgical atrioventricular block, symptomatic sick sinus syndrome, and select neuromuscular disorders.1,2 PPMs are traditionally placed using transvenous systems in adults and larger children. However, young children are often not suitable candidates due to their size or history of congenital cardiac surgery. Full-Text PDF Open Access