Ultrasound-guided thoracotomy for implantation of an epicardial left ventricular lead after left pneumonectomy

Abstract

Surgical placement of a left ventricular epicardial pacing lead is a valuable alternative to the standard approach of endovascular placement of a pacing lead in the coronary sinus for cardiac resynchronization therapy. Despite higher perioperative morbidity, surgically placed leads perform well with lower revision and dislocation rates. Moreover, surgery is the only option when an endovascular approach proves to be unsuccessful. We report a successful implantation of an epicardial left ventricular lead through an ultrasound-guided lateral left mini-thoracotomy in a patient with a severely disturbed thoracic anatomy due to left pneumonectomy.

Figure 1:

(a) Chest X-ray showing an extreme leftward displacement of the heart, right atrial (RA) and right ventricular (RV)—shock lead connected to the internal cardiac defibrillator-CRT in the right infraclavicular region. (b) LV dyssynchrony analysis from an RT3DE data set using parametric images. The global time to minimum systolic volume is used as timing reference; early segments are coded in blue, whereas late segments are coded in red. (c) a: conventional site for incision and; b: actual skin incision based on ultrasound guidance. (d) Postoperative chest X-ray with the LV-lead tunnelled around the xyphoid processus.

Figure 2:

(a) CT scan: enlargement of the right lung, lateral displacement of trachea and calcified aorta. (b) CT scan: lateral displaced of the heart and great vessels. (c) CT scan: pacemaker leads in the right atrium and shock-lead in the right ventricle. (d) CT scan: calcified venous bypass, left ventricle adjacent to the thoracic wall.