Author + information
- Mohammed Saeed, MD
Our eyes rolled as we read the recent report by DeRose et al. (1)concerning robotically assisted left ventricular epicardial lead implantation for biventricular pacing. This report joins a long progression of reports of operations, cardiac and otherwise, using the daVinci robotic surgical system. The procedure was done using double-lumen left endobroncheal intubation, single-lung ventilation, 8–10-mm Hg positive-pressure left chest insufflation, four small incisions (each likely 1 to 2 cm), and took between 30 and 180 min of robotic operating time alone (not counting double-lumen tube placement with bronchoscopic position confirmation, and robot setup time).
Our hospital also has a daVinci robot system, but we have chosen not to use it for epicardial lead placement. Rather, when difficulty has arisen with coronary sinus lead placement in the electrophysiology suite (four patients in the last few months), the generator and right-sided leads are left in place, the wound is closed, and the patient is taken to the operating room at the next convenient opening. We use a simple single-lumen endotracheal tube, a rolled towel under the left chest, and make a 6-cm or less left anterior-lateral incision with minimal spreading of the ribs using two hand-held Army-Navy retractors for left ventricular epicardial lead placement. The procedure takes about 8 to 10 min, including skin closure (even in the face of previous coronary bypass grafting). The lung is not in the way; the enlarged left ventricle rests right under the pleura in the anterior-to-mid-axillary line. No paracostal sutures are needed for closure as the ribs are essentially not spread. The patients have reported no more pain from this incision than from their pacemaker site. The skin incision is small, cosmetic, follows the natural skin lines, and rides in the subpectoral or breast-fold crease.
The available data suggest that pacing either the mid-lateral free wall (easily accessed through anterior-lateral thoracotomy) or the posterobasal left ventricle gives comparable hemodynamic results (2). We agree with the authors' assertion that these patients are fragile. Does the theoretical benefit of being able to reach the posterobasal left ventricle using the robot justify the extra cost (robot, set-up time, and disposables), extra operating time, extra manipulation (double-lumen tube with position confirmation, pulmonary artery catheter, transesophageal echocardiography, 4 incisions instead of 1, and a small drain site), and extra physiologic load (right lung ventilation, collapsed left lung with positive intrathoracic pressure)? The alternative operation is simple, inexpensive, quick, cosmetic, and truly minimally painful.
- American College of Cardiology Foundation