Long-Term Follow-Up of Isolated Epicardial Left Ventricular Lead Implant Using a Minithoracotomy Approach for Cardiac Resynchronization Therapy.

BACKGROUND: Transvenous left ventricular (LV) lead placement for cardiac resynchronization therapy is unsuccessful in 5-10% of reported cases. These patients may benefit from isolated surgical placement of an epicardial LV lead via minithoracotomy approach. AIM: To evaluate the success of this approach at long-term follow-up. METHODS: Retrospective evaluation of all consecutive patients undergoing isolated epicardial LV lead placement after failed transvenous attempt over a 6-year period. Data collected on baseline parameters, procedural details, and outcome at follow-up (hospital stay, complications, mortality, and clinical response). RESULTS: Forty-two patients underwent epicardial lead implant. Five died within 1 year (11.9%): two (4.8%) died within 30-days post op (one from intraoperative hemorrhage, the other from multiple organ failure); 39 (95.1%) were admitted to the high dependency unit and transferred to the ward <24 hours. Median hospital stay was 3.4 ± 1.9 days. The overall complication rate was 17.5% (n = 7): 15.0% (n = 6) short term and 2.5% (n = 1) long term; these included three (7.5%) LV noncapture events all treated with reprogramming. There were two (5.0%) wound infections requiring oral antibiotics and two (5.0%) device infections requiring intravenous antibiotics (one had device resiting, the other developed septic shock requiring intensive care admission). Assessment of clinical response was possible in 34 (81.0%) at follow-up: 21 (61.8%) were responders and 13 (28.2%) nonresponders with no significant differences between these groups; no clinical predictors of response were identified. CONCLUSION: Isolated epicardial LV lead implant using minithoracotomy is relatively safe and effective at successful LV pacing. Response rate and postoperative recovery at long-term follow-up are reasonable in these high-risk patients.

Primary cardiac undifferentiated sarcoma of the right atrium presenting with cardiac tamponade.

This report illustrates the serial imaging of a primary cardiac undifferentiated sarcoma of the right atrium using echocardiography, chest X-ray, and computed tomography. Transthoracic echocardiography on presentation showed an extensive mass of the right atrial free wall with an impending cardiac tamponade. Symptoms were controlled with pericardiocentesis, pericardial window, and radiotherapy but recurred 8 months later with pleural effusion and tumor spread to the great arteries. Primary cardiac sarcoma (PSC) is a rare and aggressive malignancy that is usually diagnosed late due to its nonspecific symptoms. Cytology and cardiac biopsy may be negative, and suspicion for the tumor is warranted in recurrent pericardial effusion. Analogous to parietal pleural biopsy in lung tumors with pleural effusion, parietal pericardial biopsy may be positive in PSC of the right atrium with pericardial effusion. Echocardiography is the major diagnostic tool and aids pericardiocentesis. Pericardial window may be useful for recurrent pericardial effusion but does not preclude its reaccumulation. There is no proven effective treatment for PSC, and treatments include surgical resection, cardiac transplant, chemotherapy, and radiotherapy. Despite its poor prognosis, symptomatic relief is important and attainable.

Elective intraaortic balloon counterpulsation in high-risk off-pump coronary artery bypass grafting.

The beneficial effects of intraaortic balloon pump (IABP) in CABG with cardiopulmonary bypass (CPB) have been reported. However, the benefits of insertion of IABP electively in high-risk off-pump coronary artery bypass grafting (OPCAB) have not been established. Six hundred and twenty-five patients who underwent OPCAB form the study group. High-risk patients fulfilling two or more of the following: left main stem stenosis >70%, unstable angina, and poor left ventricular function, who had elective insertion of IABP preoperatively by the open technique (group I; n = 20) were compared with a similar high-risk group that did not (group II; n = 25). There were no significant differences in risk factors between the two groups (Euroscore 5.68). The mean number of grafts was similar. Postoperatively, there were no significant differences in the need for inotropes, duration of ventilation, arrhythmias, cerebrovascular, gastrointestinal, and infective complications (p = NS). There were no IABP-related complications. Acute renal failure requiring hemofiltration was higher in group II (n = 5; p < 0.05). Four patients (16%) in group II required postoperative IABP. Although intensive care stay was longer in group I (27.6 +/- 15.3 vs. 18.6 +/- 9.1 hours; p < 0.05), patients in group I were discharged earlier from hospital. There was no difference in mortality between the two groups (n = 1 in each group). In high-risk patients undergoing OPCAB, routine preoperative insertion of IABP electively reduces the incidence of acute renal failure. In addition it avoids the need for emergency insertion postoperatively and may result in earlier discharge.