Lead Placement for Defibrillator or Pacemaker Devices
Endoscopic and Robotically-assisted Heart Surgery
Biventricular (bi-v) pacemaker
(also called cardiac resynchronization therapy or CRT)
Biventricular (bi-v) pacemakers (also called cardiac resynchronization therapy or CRT) or internal cardiac defibrillators (ICDs) are used in patients with heart failure to synchronize the ventricle’s contractions on the heart’s right and left sides and/or to prevent life-threatening arrhythmias (irregular heartbeats) in those at risk. These devices can be inserted by a cardiologist transvenously (through the veins) during a procedure in the electrophysiology lab. For a biventricular pacemaker, two leads are placed into a vein, then guided to the heart’s right atrium and right ventricle. The lead tips are attached to the heart muscle. The other ends of the leads are attached to the pulse generator, which is placed under the skin in the upper chest. The third, left ventricular lead is guided through a vein to the coronary sinus, a small vein on the back of the heart, to pace the left ventricle. The bi-v implant technique is technically challenging and is unsuccessful about 10 percent of the time due to an unfavorable location of the patient's vein.
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ICD procedures are similar, but involve only two leads. Additionally, the physician may prefer that ICD patches are sewn onto the heart’s surface rather than placed internally using the venous approach. Sometimes these devices are combined into an ICD-Bi-v pacemaker. When transvenous attempts fail or if placement of patches on the heart are preferable to catheter leads, surgery is necessary. Instead of a traditional incision, another option for lead placement is an endoscopic (small-incision) procedure. Two variations are performed at Cleveland Clinic.In the port access technique, the surgeon places one to four small (5- 10 mm) incisions or “ports” in the chest wall between the ribs. An endoscope or thoracoscope (a thin video instrument that has a small camera at the tip) and surgical instruments are placed through the incisions. The scope transmits a picture of the internal organs on a video monitor so that the surgeon has a direct, close-up view of the surgical area while placing the leads.
Robotically-assisted surgery incision
Robot-assisted heart surgery is another type of minimally invasive surgery performed by a cardiac surgeon. It involves the use of a robotic surgical system to control instruments, which are attached to thin, robotic arms. The surgeon's hands control the movement and placement of the instruments. The robotic “arm and wrist” movements mimic those of the surgeon's hand. The surgeon is always in control during the surgery, and uses robotic instrumentation to facilitate lead placement through small incisions at the side of the chest. The leads are then attached to the biventricular device (defibrillator or pacemaker) to “resynchronize” the heartbeat and improve heart failure symptoms. These endoscopic approaches are considered surgery, but the use of technology allows for very small incisions, a shorter hospital stay and a more rapid recovery compared with conventional, open-chest surgical procedures.
If you want more information about devices or endoscopic or robotically-assisted lead placement, contact us or call the Miller Family Heart & Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
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