Comparison of endovascular versus epicardial lead placement for resynchronization therapy
Naga V Garikipati1, Suneet Mittal2, Farooq Chaudhry3
1Division of Cardiology, Wright State University Boonshoft School of Medicine, Dayton, Ohio.
Insights
Robotic-assisted epicardial lead placement for cardiac resynchronization therapy (CRT) showed similar outcomes to conventional endovascular methods. This surgical approach offers a viable alternative when endovascular procedures fail or are not feasible.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Devices
Background:
- Cardiac resynchronization therapy (CRT) improves outcomes in heart failure patients with LV dysfunction and prolonged QRS.
- Left ventricular (LV) lead placement is crucial for CRT efficacy.
- Current methods include endovascular (coronary sinus) and epicardial approaches, with limited comparative data.
Purpose of the Study:
- To compare the efficacy and safety of robotic-assisted epicardial LV lead placement versus conventional endovascular LV lead placement for CRT.
- To evaluate echocardiographic and clinical outcomes between the two lead placement techniques.
Main Methods:
- A randomized trial comparing endovascular and robotic-assisted epicardial LV lead placement in eligible CRT patients.
- Primary endpoint: decrease in LV end-systolic volume index at 6 months.
- Secondary endpoints: 30-day mortality, clinical improvement, 1-year lead performance, and survival.
Main Results:
- No significant difference in LV end-systolic volume index improvement between transvenous (28.8%) and epicardial (30.5%) arms (p=0.93).
- Similar secondary outcomes, including clinical improvement and 1-year lead performance, were observed between groups.
- No significant differences in 30-day mortality or 1-year survival rates were noted.
Conclusions:
- Robotic-assisted epicardial LV lead placement is a viable alternative to conventional endovascular CRT lead placement.
- Both methods yield comparable echocardiographic and clinical outcomes.
- Surgical epicardial placement is a valuable option when transvenous procedures are unsuccessful or technically challenging.
Abstract:
Cardiac resynchronization therapy (CRT) has been shown to improve survival and symptoms in patients with severe left ventricular (LV) dysfunction, congestive heart failure, and prolonged QRS duration. LV lead placement is achieved by placing the lead in the coronary sinus, an endovascular approach, or by a minimally invasive robotic-assisted thoracoscopic epicardial approach. There are no data directly comparing the 2 methods. Patients eligible for CRT were randomized to the endovascular and epicardial arms. Coronary sinus lead placement was achieved using the standard technique, and epicardial leads were placed using a minimally invasive robotic-assisted thoracoscopic approach. The primary end point was a decrease in LV end-systolic volume index at 6 months. The secondary end points included 30-day mortality rate, measures of clinical improvement, 1-year electrical lead performance, and 1-year survival rate. The relative improvement of LV end-systolic volume index from baseline to 6 months was similar between the arms (28.8% for the transvenous [n = 12] vs 30.5% for the epicardial (n = 9) arm, p = 0.93). There were no significant differences in the secondary end points between the 2 groups. In conclusion, there were no differences in echocardiographic and clinical outcomes comparing a conventional endovascular approach versus robotic-assisted surgical epicardial LV lead placement for CRT in patients with heart failure. Surgical approaches are still a viable alternative when a transvenous procedure has failed or is not technically feasible.
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