Epicardial left ventricular lead placement for cardiac resynchronization therapy following failed coronary sinus approach.

Outcomes of surgical left ventricular (LV) lead placement in patients with failing percutaneous cardiac resynchronization therapy (CRT) are not well defined. The authors reviewed all primary epicardial LV lead placements at their institution to identify patient population, perioperative course, and structural and functional outcomes, and compared this group with patients who had successful percutaneous CRT. Fourteen patients (11%) required epicardial LV lead placement via left thoracotomy or thoracoscopy with mean intensive care unit stay of 2.1 days and inotrope use in 38%. Complications included ventricular fibrillatory arrest, stroke, hypotension, and major bleeding, but there was no difference in 90-day survival between epicardial and percutaneous CRT lead placement. In survivors, New York Heart Association class improved from 3.0 to 2.3 (P=.008) without a change in ejection fraction or severity of mitral regurgitation. Thus, in patients with unsuccessful percutaneous CRT, epicardial LV lead placement is associated with perioperative morbidity, but with subsequent improvement in functional status without excess mortality.