Robotically-guided approach offers alternative LV lead implantation through the coronary sinus

Sana Amraoui

Left ventricular (LV) lead implantation for cardiac resynchronisation therapy (CRT) with a robotically-guided surgical approach through the coronary sinus seems to offer a new alternative when conventional approaches are not suitable, a new study has found.


“Left ventricular lead implantation through the coronary sinus is frequently challenging, and lead position is restricted by the coronary sinus anatomy,” write Sana Amraoui (Université de Bordeaux, Hôpital Haut-Lévêque, LIRYC, Bordeaux-Pessac, France) in Europace.

“Minimally invasive, robotically-guided LV lead implantation has major advantages, but there are little published data about the short- and long-term follow-up, in terms of feasibility, safety, electrical performance, and impact on clinical outcome,” note Amraoui et al; therefore, they set out to prospectively evaluate the role of minimally invasive robotic surgical LV lead implantation, in patients who had previously undergone a failed conventional approach.

Twenty-one heart failure patients (69±8 years, five females, with LV ejection fraction ≤35%, drug refractory heart failure, and electrical dyssynchrony-QRS duration ≥120ms-with left bundle branch block) underwent robotically-guided LV lead implantation with the Da Vinci Robotic System (Intuitive Surgical). Sixteen patients had previously failed implants with conventional approach and five were non-responders to conventional cardiac resynchronisation therapy.

The procedure was performed in a cardiothoracic surgical theatre under general anaesthesia.

The researchers assessed short-term events including: peri-procedural complication rate, procedure-related mortality, hospitalisation time and lead performance. Additionally, long-term events including: CRT response, remote complications and lead performance were also evaluated.

The authors reported that robotically-guided LV lead implantation was successfully performed in all 21 patients with an average procedure time of 48±19 minutes. They explain that during the procedure the whole LV epicardium was exposed and therefore multiple LV sites were available, avoiding coronary arteries, phrenic nerve, and scar zones. Amraoui et al note that no phrenic nerve stimulation cases were reported.

Additionally, there were not peri-procedural complications and after a mean stay of 1.2±4 days in the intensive care unit, the 21 patients were hospitalised in the electrophysiology department for 6.7±2.9 days.

A total of 57% of patients were responders and “acute LV thresholds were excellent (1.0V±0.6/0.4ms)” and stayed stable at one-year follow-up (1.5V±0.6/0.4ms, p=0.21), Sana et al reported.

The authors also highlight that short procedure time, lack of any requirement for X-ray fluoroscopy, and minimally invasive nature of the procedure are significant advantages with this approach.

In conclusion, Amraoui et al write: “In this feasibility study, robotic bifocal LV lead implantation can be seen to provide advantages that might prove beneficial, particularly where the conventional transvenous approach has previously failed…The robotic approach does not replace the coronary sinus method, but it is proposed as an alternative technique to conventional approach in difficult cases.”

“This approach could also be proposed at the first line in some cases, like young patients, in order to protect the venous accesses and to decrease the risk of infection, or in patients with high risk of lead infection.”