Robotic-Assisted Epicardial Pacemaker Lead Placement

Patients experiencing altered interventricular conduction delay and congestive heart failure often witness an improved quality of life and enhanced ventricular function through biventricular pacing therapies (1). However, intravascular pacemaker leads can lead to complications such as superior vena cava (SVC) syndrome, an infrequent yet significant issue following pacemaker lead implantation. In these instances, the alternative option of intravascular lead removal followed by surgical epicardiac pacemaker lead implantation becomes prominent. The traditional method for placing epicardial pacemaker leads involves sternotomy. However, alternative options, including thoracotomy and thoracoscopic procedures with or without robotic assistance, are also available (2). Robotic assistance in implanting epicardial pacemaker leads is a secure and effective technique, providing advanced visualization and precision for accurately targeting the optimal pacing site (2,3).

In this video, the authors share their experience with robotic-assisted epicardial pacemaker lead placement in two clinical scenarios, resulting in successful outcomes in both a first-time and redo setting.



The first patient, a thirty-seven-year-old female, was pacemaker dependent and developed SVC syndrome with narrowing and stenosis of the subclavian vein and innominate SVC junction. With a history of pneumothorax and pleurodesis on the right hemithorax and a preference to avoid sternotomy, surgeons offered a robotically assisted left-sided pacemaker placement. The surgical plan included previous lead extraction, subclavian and innominate balloon venoplasty, and robotic epicardial pacemaker lead placement. All procedures concluded without complications, with two leads implanted in the left atrial appendage and two in the lateral wall of the left ventricle. The postoperative course was uneventful, leading to discharge on postoperative day two.

The second patient, a fifty-year-old male with a prior sternotomy for atrial septal defect repair, had a dual chamber permanent pacemaker with the right lead requiring reimplantation due to device endocarditis and complicated by SVC syndrome. The patient required an atrial pacemaker lead so surgeons dissected the pericardium off the atrium using robotic cautery and blunt dissection, securing two atrial leads to the atrium. The pericardium was then closed. The procedure proceeded without complications, with two epicardial leads successfully implanted in the right atrial wall. The postoperative course was uneventful, resulting in discharge on postoperative day one.

References

1. Derose JJ Jr, Belsley S, Swistel DG, Shaw R, Ashton RC Jr. Robotically assisted left ventricular epicardial lead implantation for biventricular pacing: the posterior approach. Ann Thorac Surg. 2004 Apr;77(4):1472-4.
2. Bhatt AG, Steinberg JS. Robotic-Assisted Left Ventricular Lead Placement. Heart Fail Clin. 2017 Jan;13(1):93-103.
3. DeRose JJ, Ashton RC, Belsley S, Swistel DG, Vloka M, Ehlert F, et al. Robotically assisted left ventricular epicardial lead implantation for biventricular pacing. J Am Coll Cardiol. 2003 Apr 16;41(8):1414-9.

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