Lateral thoracotomy for epicardial pacemaker placement in patients with congenital heart disease

Troubleshooting During Temporary Epicardial Lead Implantation in a Child with an Erosive Twiddler's Syndrome and Multiple Sternotomies: A case report

Temporary epicardial cardiac pacing in patients with bradyarrhythmias may be used as a bridge to implantation of a permanent pacemaker. The temporary epicardial lead placement may sometimes necessitate a sternotomy that may pose a challenge in patients who have had multiple earlier sternotomies. The difficulty in accessing the epicardium for urgent implantation of temporary epicardial pacing leads depends on the extent of adhesions in such patients. We report an 8-year-8-month-old girl with a pacemaker with an extruded pulse generator and difficult myocardial access due to 5 prior transsternal procedures. The child presented to a tertiary care hospital in Muscat, Oman, in 2021. A trouble-shooting technique was adopted to achieve temporary epicardial pacing to provide time for a course of antibiotic therapy administration. A permanent transvenous pulse generator system was implanted after 7 days of temporary pacing.

Percutaneous epicardial pacing in infants using direct visualization: A feasibility animal study

BACKGROUND

Pacemaker implantation in infants and small children is limited to epicardial lead placement via open chest surgery. We propose a minimally invasive solution using a novel percutaneous access kit.

OBJECTIVE

To evaluate the acute safety and feasibility of a novel percutaneous pericardial access tool kit to implant pacemaker leads on the epicardium under direct visualization.

METHODS

A custom sheath with optical fiber lining the inside wall was built to provide intrathoracic illumination. A Veress needle inside the illumination sheath was inserted through a skin nick just to the left of the xiphoid process and angled toward the thorax. A needle containing a fiberscope within the lumen was inserted through the sheath and used to access the pericardium under direct visualization. A custom dilator and peel-away sheath with pre-tunneled fiberscope was passed over a guidewire into the pericardial space via modified Seldinger technique. A side-biting multipolar pacemaker lead was inserted through the sheath and affixed against the epicardium.

RESULTS

Six piglets (weight 3.7-4.0 kg) had successful lead implantation. The pericardial space could be visualized and entered in all animals. Median time from skin nick to sheath access of the pericardium was 9.5 (interquartile range [IQR] 8-11) min. Median total procedure time was 16 (IQR 14-19) min. Median R wave sensing was 5.4 (IQR 4.0-7.3) mV. Median capture threshold was 2.1 (IQR 1.7-2.4) V at 0.4 ms and 1.3 (IQR 1.2-2.0) V at 1.0 ms. There were no complications.

CONCLUSION

Percutaneous epicardial lead implantation under direct visualization was successful in six piglets of neonatal size and weight with clinically acceptable acute pacing parameters.

Considerations in Critical Care and Anesthetic Management of Adult Patients Living with Fontan Circulation

The Fontan procedure is a staged palliation for various complex congenital cardiac lesions, including tricuspid atresia (TA), pulmonary atresia (PA), hypoplastic left heart syndrome (HLHS), and double inlet left ventricle (DILV), all of which involve a functional single-ventricle physiology. The complexity of the patients' original anatomy combined with the anatomical and physiological consequences of the Fontan circulation creates challenges. Teens and adults living with Fontan palliation will need perioperative support for non-cardiac surgery, peripartum management for labor and delivery, interventions related to their structural heart disease, electrophysiology procedures, pacemakers, cardioversions, cardiac surgery, transplant, and advanced mechanical support. This review focuses on the anesthetic and ICU management of these patients during their perioperative journey, with an emphasis on the continuity of pre-intervention planning, referral pathways, and post-intervention intensive care unit (ICU) management. Requests for recipes and doses of medications are frequent; however, as in normal anesthesia and ICU practice, the method of anesthesia and dosing are dependent on the presenting medical/surgical conditions and the underlying anatomy and physiological reserve. A patient with Fontan palliation in their early 20s attending school full-time with a cavopulmonary connection is likely to have more reserve than a patient in their late 40s with an atrio- pulmonary (AP) Fontan at home waiting for a heart transplant. Each case will require an anesthetic and critical care plan tailored to their situation. The critical care environment is a natural extension of the anesthetic management of a patient, with complex considerations for a patient with Fontan palliation.

The role of cardiac surgeon in transvenous lead extraction: experience from 3462 procedures

INTRODUCTION

The professional society guidelines recommend that transvenous lead extraction (TLE) operating teams collaborate closely with cardiac surgeons in the management of life-threatening complications.

METHODS AND RESULTS

We assessed the role of cardiac surgeons participating in 3462 TLE procedures at a high-volume center between 2006 and 2021. The roles for cardiac surgery in TLE can be categorized into five areas: emergency surgical interventions for the management of cardiac laceration and severe bleeding (1.184%), cardiac surgery complementing partially successful TLE or vegetation removal (0.693%), delayed surgical treatment of TLE-related tricuspid valve dysfunction (0.751%), epicardial pacemaker implantation through sternotomy during emergency, complementing or delayed surgical interventions (0.607%) and delayed epicardial lead implantation (0.491%). Isolated damage to the wall of the right atrium was the most common cause of cardiac tamponade (53.66% of emergency surgeries) followed by injury to the right ventricle and vena cava (both 7.317%).

CONCLUSIONS

Emergency cardiac surgery for the management of severe hemorrhagic complications is still the most common treatment option. The remaining areas include surgery complementing partially successful TLE: repair of tricuspid valve or epicardial ventricular lead placement to achieve permanent cardiac resynchronization. The experience at a single high-volume TLE center indicates the necessity of close collaboration with the cardiac surgeons whose roles appear broader than the mere surgical standby. Mortality in patients who survived cardiac surgery during transvenous lead extraction does not differ from the survival of other patients after TLE without complications requiring surgical intervention. This article is protected by copyright. All rights reserved.

Impact of the axillary approach on epicardial pacing lead durability in children

BACKGROUND

To avoid lead failure and pocket infection in neonates/infants requiring pacemakers, we used the axillary approach of placing the generator in the axilla and the leads in the intrathoracic space. We describe the technical details of the axillary approach and evaluate the efficacy of this method.

METHODS

We assessed 21 patients (7 males) weighing ≤8.0 kg who underwent epicardial pacemaker implantation with the axillary approach between 2004 and 2018. The axillary approach entails (1) positioning the pacemaker generator in the axilla to avoid local skin/pocket complications due to tissue compression by the generator and (2) making a double loop in the pleural space to reduce stress on the pacemaker leads caused by somatic growth. This approach can be combined with median sternotomy for simultaneous intracardiac repair.

RESULTS

The patients' median age at pacemaker implantation was 6.0 months; 16 (76%) patients were aged <12 months. The median body weight was 4.5 kg (interquartile range: 3.0-7.0). In all five patients requiring simultaneous cardiac repair, a median sternotomy was performed to access the heart. Sixteen patients required only pacemaker implantation: left thoracotomy was performed in 10 patients, right thoracotomy in 5, and subxiphoid approach in 1. The 5- and 10-year freedom from pacemaker-related adverse events was 89.4% and 79.5%, respectively.

CONCLUSIONS

The axillary approach using intrathoracic double-loop routing of leads to position the generator in the axilla for pacemaker implantation can be a valuable alternative for neonates/infants weighing ≤8 kg with or without complex congenital heart disease.

Borrowing from Adult Cardiac Surgeons-Bringing Congenital Heart Surgery Up to Speed in the Minimally Invasive Era

The majority of congenital and adult cardiac surgery is performed through a median sternotomy. For surgeons, this incision provides excellent exposure; however, for patients, a median sternotomy confers a poorer cosmetic outcome and the possibility of postoperative respiratory dysfunction, chronic pain, and deep sternal wound infections. Despite the advances in adult cardiac surgery, the use of minimally invasive techniques in pediatric patients is largely limited to small case series and less complex repairs. In this article, we review the risks, benefits, and limitations of the minimally invasive congenital cardiac approaches being performed today. The interest in these approaches continues to grow as more data supporting reduced morbidity, decreased length of stay, and faster recovery are published. In the future, as the technology and surgical familiarity improve, these alternative approaches will become more common, and may someday become the standard of care.

Surgical pericardial adhesions do not preclude minimally invasive epicardial pacemaker lead placement in an infant porcine model

BACKGROUND

Pericardial adhesions in infants and small children following cardiac surgery can impede access to the epicardium. We previously described minimally invasive epicardial lead placement under direct visualization in an infant porcine model using a single subxiphoid incision. The objective of this study was to assess the acute feasibility of this approach in the presence of postoperative pericardial adhesions.

METHODS

Adhesion group piglets underwent left thoracotomy with pericardiotomy followed by a recovery period to develop pericardial adhesions. Control group piglets did not undergo surgery. Both groups underwent minimally invasive epicardial lead placement using a 2-channel access port (PeriPath) inserted through a 1 cm subxiphoid incision. Under direct thoracoscopic visualization, pericardial access was obtained with a 7-French sheath, and a pacing lead was affixed against the ventricular epicardium. Sensed R-wave amplitudes, lead impedances and capture thresholds were measured.

RESULTS

Eight piglets underwent successful pericardiectomy and developed adhesions after a median recovery time of 45 days. Epicardial lead placement was successful in adhesion (9.5 ± 2.7 kg, n = 8) and control (5.6 ± 1.5 kg, n = 7) piglets. There were no acute complications. There were no significant differences in capture thresholds or sensing between groups. Procedure times in the adhesion group were longer than in controls, and while lead impedances were significantly higher in the adhesion group, all were within normal range.

CONCLUSIONS

Pericardial adhesions do not preclude minimally invasive placement of epicardial leads in an infant porcine model. This minimally invasive approach could potentially be applied to pediatric patients with prior cardiac surgery.

A Minimally Invasive Approach for Placing Sew-On Epicardial Leads in the Child

Traditionally, pacing leads are placed transvenously, although smaller pediatric patients who require permanent pacemakers may benefit from delaying tranvenous lead placement until they are larger. Alternative, minimally invasive atrioventricular pacing options have not previously existed for this patient population, leaving many of these children with large sternotomies or thoracotomies. Using three port sites and an adjustable shaft dual-needle suturing device, we placed a steroid-eluting, sew-on epicardial lead on the right atrium of a 9-year-old patient. This is one of the earliest reported cases of a minimally invasive technique for sew-on epicardial lead placement on the atrium of a child. Although based on a single case, we believe that this approach is safe, reliable, and reproducible and that it can be used to place leads on any aspect of the heart. Adoption of this technique will allow for earlier atrioventricular pacing, which may decrease the incidence of pacemaker syndrome, and thus improve overall outcomes in this patient population.