Feasibility of percutaneous implantation of transapical endocardial left ventricular pacing electrode for cardiac resynchronization therapy

Failure of coronary sinus lead implantation for resynchronization therapy requires alternative approaches. For such events we have developed a transapical implantation technique as a feasible alternative. We report the outcome of this technique and its evolution from a minithoracotomy to a percutaneous approach. Twenty patients underwent alternative resynchronization therapy with transapical endocardial left ventricular (LV) pacing lead implantation in a multicentre, international study between October 2007 and March 2010. Eighteen patients underwent minithoracotomy and transapical puncture under direct observation. Two recent patients had transthoracic echocardiography-guided percutaneous apical puncture to enter the LV cavity. A 19 or 21 ga needle and two-stage Seldinger dilatation with 4 and 7 Fr sheaths were then used to introduce the lead. In the two patients with closed-chest insertion of the electrode there was no puncture related bleeding or lung damage. Lead dislocation occurred in two minithoracotomy patients. Repositioning was performed without re-opening the pleural cavity. One patient developed right-sided implanted cardiac defibrillator lead endocarditis requiring complete system removal. Twelve patients have >1 year follow-up; all have sustained and significant improvement in LV dimensions (diastolic Δ4.2 ± 2.9, systolic Δ7.2 ± 5.8 mm), ejection fraction (Δ9.5 ± 9.6%), and functional status (Δ1.1 ± 0.3). Transapical placement of LV endocardial pacing lead is an effective alternative strategy for cardiac resynchronization. A closed-chest, percutaneous approach is feasible and should offer even less invasive intervention.

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