Implantation thoracoscopique de pacemaker

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Implantation thoracoscopique de pacemaker

Thoracoscopic vs conventional
trans-diaphragmatic pacemaker implantation :
comparative study in 4 cases

Auteurs: Drs. S.Libermann et É.Bomassi 24-04-2013
Centre Hospitalier Vétérinaire des Cordeliers, 29 avenue du Maréchal Joffre, 77100 Meaux.
E-mail: slibermann@chvcordeliers.com, ebomassi@chvcordeliers.com
Conférence

Introduction

Transvenous pacemaker implantation is safe

  • All dogs survived implantation in studies [1] and [2], 6 cardiac arrest in [3]
  • Major complications (15/104, Johnson and al. – 12/105, Wess and al., 51/136 Oyama and al.)
  • Lead displacement >>> infection, bleeding

Transvenous pacemaker implantation is successful in reducing clinical signs in sick sinus syndrome or third degree atrioventricular block

  • Mean survival times (2,2 years Wess and al.)
  • One-, three and five years survival : 86%, 65%, 39% (Johnson and al.)
  • One, two and three years survival : 70 %, 57 %, 45 % (Oyama and al.)

→ Gold Standard

[1] Results of pacemaker implantation in 104 dogs, M.S. Johnson, M.W.S Martin, W Henley, (2007) JSAP 48:4-11
[2] Applications, complications and outcomes of transvenous pacemaker implantation in 105 dogs (1997-2002), G Wess, W.P. Thomas, D.M. Berger, M.D. Kittleson, (2006) J Vet Intern Med 20(4):877-84
[3] Practices and outcomes of artificial cardiac pacing in 154 dogs, M.A. Oyama, D.D. Sisson, L.B. Lehmkuhl (2001), J Vet Intern Med 15(3):229-39

Interests of transvenous pacemaker implantation

  • Minimally invasive

Limits of transvenous pacemaker implantation :

  • Injury / sepsis in the area of right jugular vein
  • Price
  • Available
  • NO SURGEON NEEDED

Study design

Prospective case serie

Animals

  • Sick sinus syndrome (1), Sinoatrial block (1),
    Atrioventricular block and non active or old myocarditis suspected (2)

cadaveric study conducted to compare the epicardial access for implantation

Procedure

Dogs randomly assigned to:

  • group 1 = conventional Trans-diaphragmatic approach(TDA)
  • group 2 = Thoracoscopic implantation (TI)
    • Dorsal recumbancy
    • 5 mm telescope / paraxyphoïd approach
    • Instruments portals en in 6th intercostal space – left 15mm – Right 5 mm
    • Pericardial window
    • Myocardic biopsy
Photo 1
Photo 2

Photos 1&2:
Thoracoscopic pericardectomy performed without pulmonary exclusion in 9 dogs.
Dupré G, Corlouer J, Bouvy B (2001). Vet Surg 30(1)21-7

Leads

  • Medtronic Unipolar electrodes for single chamber pacing
  • Capsure EPI 4965 coated with steroïds
  • Suturelessunipolar myocardial screw-in pacing lead

lib - 240413 - ca3b1 - 4

  • Pulse generator : VVIR Medtronic ADAPTA ADSR 01

 

 

 

 

 

 

Photo 1
Photo 2
  • 15 mm portal for lead implatation
  • Lead and electrode positionning
  • Controle pacing
Photo 3

lib - 240413 - ca3b1 - 9

 

Photo 4
Photo 5
Photo 6
Photo 7
Photo 8

Anatomic study

  • Both procedures done on a cadaver
  • Epicardium marked on the insertion sites by Ligasure
  • Full heart dissection
Photo 1


Results

  • Animals
 Group

Male
Female

Weight

Age

Breed

1 al 1

M

9,6 kg

11

WHWT

1 al 2

M

35 kg

7

Labrador

2 al 1

M

37 kg

10

S. Husky

2 al 2

F

27,5 kg

11

Weimaraner
  • Surgical time
    • 46’ and 43 ‘ in Group 1
    • 44’ and 22’ in Group 2
  • 1 major complication in Group 2 case 2
    • Pigtail loss, thoracoscopic reimplantation needed Twiddler syndrome
  • Biopsy
    • Old myocarditis confirmed in both cases of Group 2
    • Biopsy had no consequence on cardiac pacing
  • Outcomes
    • Hospital discharge 3 and 4 days PO in group 1 1 and 2 days PO in group 2
    • All dogs free of cardiac symptomes

Discution

  • Anatomic study
    • Transdiaphragmatic approach : Left ventricle
    • Thoracoscopic implantation : Right ventricle
    • +: more consistent with human guidelines
    • -: thinner myocardium in dogs  risk of pigtail loss??
  • Right 6th intercostal portal can be used for electrode implantation

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  • Feasability of thoracoscopic pacemaker lead implantation
    • Easy
    • Faster than TDA
    • Early hospital discharge
  • Complication in group 2 (twiddler syndrome)
    • Lead displacement due to anormal coiling
      → wrong position of the generator
    • NOT due to the thoracoscopy

lib - 240413 - ca3b1 - 19

  • Thoracoscopic implantation > Thoracotomy
  • TI > Trans-diaphragmatic approach
  • T I > trans-xyphoïd approach ?
Minimal invasive transxiphoie approach to the cardiac apex and caudoventral intrathoracic space, D.A. Nelson and al. (2012) Vet Surg 41:915-7

Minimal invasive transxiphoie approach to the cardiac apex and caudoventral intrathoracic space, D.A. Nelson and al. (2012) Vet Surg 41:915-7

  • Risks in endovascular implantation :
    • Thrombosis [1]
    • Obstruction [2,3]
    • Stricture [4]
  • TI possible for dual chamber pacing : access allowed to the right auricule

[1]Cranial vena cava thrombosis associated with endocardial pacing leads in three dogs.
Murray J, O’Sullivan ML? Hawkes KC. J Am Anim Hosp Assoc. 2010 May-Jun;46(3):186-92
[2] Caudal vena cava obstruction caused by redundant pacemaker lead in a dog
Stauthammer C, Tobias A, France M, Olson J J Vet Cardiol 2009 Dec;11(2):141-(
[3] Cranial vena caval syndrome secondary to central venous obstruction associated with a
Pacemaker lead in a dog Mulz JM, Kraus MS, Thompson M, Flanders JA J Vet Cardiol 2010. Dec 12(3):217-23
[4] Succesful treatment of pacemaker-induced stricture and thrombosis of the cranial vena cava in two dogs by use of anticoagulants and balloon venoplasty. Cunningham SM, Ames MK, Rush JE, Rozanski EA.
J Am Vet Med Assoc 2009 Dec 15;235(12):1467-73

Conclusion

  • TI seems to be effective
  • Minimal invasive surgery
  • Can be an interesting alternative to endovascular implantation?

Recherche