Concomitant Transatrial and Transapical CRT-D Lead Implantation in a Patient with Chest Burn Injury

Abstract

Cardiac resynchronization therapy device with defibrillator (CRT-D) implantation is indicated for patients with a history of malignant ventricular arrhythmias, symptomatic heart failure, wide QRS, or high-degree atrioventricular block. A 67-year-old patient with dilated cardiomyopathy received a CRT-D with the conventional method but 1 month later skin necrosis was diagnosed above the device. The complete system was extracted from the patient and we utilized negative pressure wound therapy for the treatment of the remaining tissue. We decided to perform surgical reimplantation of the device using minithoracotomy: right atrial and right ventricular leads were introduced through the right atrial appendage and the left ventricular lead was inserted transapically. The device was implanted under the less scabby abdominal skin. We successfully applied the combination of transatrial and transapical lead placement, which has not been reported in the literature yet. It serves as an alternative method if the standard approach is not feasible.

Keywords: heart failure; minimally invasive surgery (includes port access, minithoracotomy); wound healing.

Fig. 1

( A ) Three weeks after the implantation. ( B ) The complete system was removed, and a large tissue gap remained. ( C ) Negative pressure of 125 mm Hg was applied, to cover the tissue defect and facilitate tissue regrowth. ( D ) Three weeks after the device explantation. With continuous negative pressure wound therapy, the absence of skin tissue was almost completely closed.

Fig. 2

Surgical cardiac resynchronization therapy device with defibrillator (CRT-D) implantation. ( A ) Right lateral minithoracotomy. The right ventricular and right atrial leads are positioned and fixed with purse-string sutures. ( B ) Left lateral minithoracotomy. The left ventricular lead was introduced through the apex of the left ventricle. ( C ) The leads were pulled through tunnels into the abdominal part and attached to the CRT-D device. ( D ) Positioning of the leads was performed with fluoroscopy guidance. ( E ) Good parameters were recorded at the end of the procedure. ( F ) Six months after the surgery.