Heart Institute, Medical School, University of Pécs, Pécs, Hungary.
Szentágothai Research Centre, University of Pécs, Pécs, Hungary.
Pacing Clin Electrophysiol. 2021 Jan;44(1):101-109. doi: 10.1111/pace.14123. Epub 2020 Nov 26.
Cardiac resynchronization therapy (CRT) is considered an efficient method to improve the left ventricular (LV) dysfunction with left bundle branch block. However, coronary venous anatomy is not appropriate in about 10% of the cases; thus other alternatives, such as epicardial lead implantation via minithoracotomy are needed.
During the period 2007-2017, a total of 57 patients were operated at our institute via left anterior minithoracotomy after an unsuccessful transvenous CRT. The best position of the LV epicardial electrode was determined by intraoperative epicardial mapping, that is locating the latest activation spot relative to the right ventricular (RV) electrode. The authors analyzed the survival by Kaplan-Meier estimator with Tarone-Ware equality test and multiple Cox regression analysis, the changes of the LV ejection fraction (LVEF) and dimensions, the development of the impedance and threshold of the LV epicardial electrode, the possible associations between the survival and intraoperative sensed RV-LV activation delay.
The intraoperative RV-LV activation delay was 92.250 ± 26.538 milliseconds. There were no intraoperative complications except ventricular fibrillation in three patients. Within 30 days there were neither wound healing complications nor pocket hematoma. There was no significant difference in survival with regard to gender or etiology, but significantly better survival was found in the cohort with intraoperative sensed RV-LV activation delay >86 milliseconds. The LVEF and dimensions improved following the operation and continued to be improved in the survivors.
CRT via minithoracotomy with epicardial mapping is a safe, efficient, simple, and reproducible second-line alternative to the transvenous method.
心脏再同步治疗（CRT）被认为是改善左束支传导阻滞伴左心室（LV）功能障碍的有效方法。然而，约有 10%的病例冠状静脉解剖结构不合适；因此，需要其他替代方法，如经小开胸术植入心外膜导联。
在 2007 年至 2017 年期间，我们机构对 57 例经静脉 CRT 失败的患者通过左侧前小开胸术进行手术。通过术中的心外膜标测确定 LV 心外膜导联的最佳位置，即相对于右心室（RV）导联定位最晚激活点。作者采用 Kaplan-Meier 估计器和 Tarone-Ware 均等检验及多 Cox 回归分析对生存率进行分析，分析 LV 射血分数（LVEF）和心腔尺寸的变化，LV 心外膜导联的阻抗和阈值的发展，以及生存率与术中感知的 RV-LV 激活延迟之间的可能关联。
术中 RV-LV 激活延迟为 92.250 ± 26.538 毫秒。除了 3 例患者发生心室颤动外，术中无并发症。术后 30 天内，无伤口愈合并发症或囊袋血肿。在性别或病因方面，生存率无显著差异，但在术中感知的 RV-LV 激活延迟>86 毫秒的患者中，生存率显著提高。LVEF 和心腔尺寸在手术后改善，并在存活者中持续改善。
经小开胸术结合心外膜标测的 CRT 是一种安全、有效、简单、可重复的经静脉方法的二线替代方法。
