Transatrial Implantation of Transvenous Pacing Leads is an Alternative to Implantation of Epicardial Leads

Abstract

State-of-the-art pacing modalities are not readily utilized with conventional epicardial pacing lead implantation techniques. A transatrial implantation technique was developed combining a limited surgical approach with transvenous leads. Six patients who were poor candidates for transvenous implants have received DDD or DDDR pacemakers by this approach. The limited surgical approach includes resection of the third or fourth costal cartilage through a small skin incision, reflection of the pleura, and opening of the pericardium. The introducer and transvenous leads are inserted through a right atrial pursestring suture. The leads are positioned in the right ventricle and right atrium using standard fluoroscopic techniques. Through the incision, the subcutaneous tissue pocket is constructed on the right anterior chest wall. The leads are connected to the pacemaker without the need for adaptors or tunneling. There were no procedure-related complications. The magnitude of the surgery and postoperative morbidity are significantly less than for a standard thoracotomy, median sternotomy, and transdiaphragmatic epigastric or subcostal approach. The utility of the transatrial implantation technique is that it allows the use of state-of-the- art bipolar dual chamber pacemakers restoring access to all pacing modalities for those patients not candidates for transvenous implantation.

Long-Term Follow-Up Shows Excellent Transmural Atrial Lead Performance in Patients With Complex Congenital Heart Disease

“…9,10 Epicardial lead sites can be also be problematic because patients frequently have extensive epicardial scarring because of multiple re-entry sternotomies and may have surgical patches or extensive atrial suture lines limiting availability of an appropriate epicardial site for lead implantation. [2][3][4][5][6][7][8] Transmural placement of atrial pacing leads has been previously described [11][12][13][14] and has been performed on selected patients at our institution since 1998. The present analysis of chronic TMA lead performance validates the use of this approach as a practical and appropriate treatment option.…”

“…[11][12][13][14] Figure 1 illustrates the technique used to implant the TMA pacing leads, including representative chest radiographs. Leads were implanted using a purse-string incision in the atrial wall or during closure of the atriotomy incision done as part of concurrent surgical procedure.…”

Strategies for Transvenous Lead Extraction Procedures

“…15 Locking stylets were developed to reinforce the lead, transmit the extraction force to the tip of the lead, reduce the risk of lead disruption, and increase the likelihood of complete lead removal. [16][17][18] Several types of locking stylets have been designed. While the original locking stylets had to be sized to the luminal diameter of the conductor coil, the most commonly utilized locking stylets today are designed to accommodate a range of conductor coil diameters.…”

“…implant vein) approach range from 71% to 97%. 16,17,20,21 Powered sheaths. Powered sheaths employ a source of energy to make the dissection of encapsulating fibrous tissue easier and more efficient.…”

“…Once the lead is released from the fibrous tissue, the myocardium falls away from the sheath, thereby reducing the risk of myocardial invagination or injury ( Figure 14). 16,20,38 Lead extraction approach Leads are typically extracted by a superior approach via the implant vein, although alternative approaches are used in certain situations. For example, when the free lead tip cannot be reached from the implant vein, an inferior approach via the femoral vein is necessary.…”