The Surgeon's Role in Resynchronization Therapy

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Abstract

Surgeons have contributed studies of the pathophysiology and treatment of arrhythmias in experimental animals and patients during thoracotomy. This research has involved epicardial1 and endocardial2 pacemakers and implantable cardioverter–defibrillators (ICDs).3 Surgeons helped to define the mechanisms and ablation methods for supraventricular arrhythmias (including Wolff-Parkinson-White syndrome)4 and for ventricular tachycardia associated with post-infarction, ventricular aneurysms,5 and other conditions.6 In congenital heart disease, techniques for mapping the conduction system were developed by surgeons and used to avoid heart block during surgical repair.7 Therapies for atrial fibrillation developed in the operating room include atrioventricular node ablation8 or modification9 and the Cox-maze operation.10 Mapping and ablation technologies developed by surgeons have evolved to standard methods used in the electrophysiology lab.

Citation
US Cardiology - Volume 5 Issue 1;2008:5(1):70-71

Pages

Surgeons have contributed studies of the pathophysiology and treatment of arrhythmias in experimental animals and patients during thoracotomy. This research has involved epicardial1 and endocardial2 pacemakers and implantable cardioverter–defibrillators (ICDs).3 Surgeons helped to define the mechanisms and ablation methods for supraventricular arrhythmias (including Wolff-Parkinson-White syndrome)4 and for ventricular tachycardia associated with post-infarction, ventricular aneurysms,5 and other conditions.6 In congenital heart disease, techniques for mapping the conduction system were developed by surgeons and used to avoid heart block during surgical repair.7 Therapies for atrial fibrillation developed in the operating room include atrioventricular node ablation8 or modification9 and the Cox-maze operation.10 Mapping and ablation technologies developed by surgeons have evolved to standard methods used in the electrophysiology lab.
However, the development of resynchronization therapy for heart failure has largely bypassed the surgical arena. The epicardial approach has been marginalized as catheter technology has advanced and concern about the risks of general anesthesia and thoracotomy in patients with advanced heart failure has grown.11 However, arguably, the minimization of surgical contributions to resynchronization therapy has left important gaps in the understanding of how resynchronization therapy works, where it should be applied, and how it can be optimized. Following the early success of the Multicenter InSync Randomized Clinical Evaluation (MIRACLE) trial,12 implantation of biventricular pacemakers and pacemaker ICDs has expanded explosively. The worldwide market for resynchronization devices in 2007 is estimated to be in excess of 300,000 implants annually, at a market value of more than $7 billion for devices alone. However, with an incidence of non-responders of 25–30%13 (39% in the MIRACLE trial12), roughly 90,000 of 300,000 recipients this year will not experience relief from symptoms of heart failure or functional benefit. While patients may benefit from defibrillation capabilities in these implants, the healthcare community will pay more than $2 billion for ineffective resynchronization therapy. Why does resynchronization therapy fail, and how can surgical investigators help?

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References
  1. Weirich WL, Paneth M, Gott VL, Lillehei CW, Control of complete heart block by use of an artificial pacemaker and a myocardial electrode, Circ Res, 1958;6:410–15.
    Crossref | PubMed
  2. Furman S, Schwedel JB, An intracardiac pacemaker for Stokes-Adams seizures, N Engl J Med, 1959;261:943–8.
    Crossref | PubMed
  3. Bigger JT Jr, for the Coronary Artery Bypass Graft (CABG) Patch trial Investigators, Prophylactic use of implanted cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary-artery bypass graft surgery, N Engl J Med, 1997;337:1569–75.
    Crossref | PubMed
  4. Sealy WC, Hattler BG Jr, Blumenshein SD, Cobb FR, Surgical treatment of Wolff-Parkinson-White Syndrome, Ann Thorac Surg, 1969;8:1–11.
    Crossref | PubMed
  5. Josephson ME, Harken AH, Horowitz LN, Endocardial excision: a new surgical technique for the treatment of recurrent ventricular tachycardia, Circulation, 1979;60:1430–39.
    Crossref | PubMed
  6. Cox JL, Cardiac surgery for arrhythmias, J Cardiovasc Electrophysiol, 2004;15:250–62.
    Crossref | PubMed
  7. Gallagher JJ, Kasell JH, Cox JL, et al., Techniques of intra-operative electrophysiologic mapping, Am J Cardiol, 1982;49:221–40.
    Crossref | PubMed
  8. Harrison L, Gallagher JJ, Kasell J, et al., Cryosurgical ablation of the A-V node His bundle: A new method for producing A-V block, Circulation, 1977;55:463–70.
    Crossref | PubMed
  9. Cox JL, Ferguson TB Jr, Lindsay BD, Cain ME, Perinodal cryosurgery for atrioventricular node reentry tachycardia in 23 patients, J Thorac Cardiovasc Surg, 1990;99:440–49.
    PubMed
  10. Cox JL, Schuessler RB, D’Agostino HJ Jr, et al., The surgical treatment of atrial fibrillation, III: development of a definite surgical procedure, J Thorac Cardiovasc Surg, 1991;101:569–83.
    PubMed
  11. Leclercq C, Cazeau S, Ritter P, et al., A pilot experience with permanent biventricular pacing to treat advanced heart failure, Am Heart J, 2000;140:862–70.
    Crossref | PubMed
  12. Abraham WT, Fisher WG, Smith AL, et al., Multicenter InSync Randomized Clinical Evaluation. Cardiac resynchronization in chronic heart failure, N Engl J Med, 2002;346:1845–53.
    Crossref | PubMed
  13. Kass DA, Predicting cardiac resynchronization response by QRS duration: the long and short of it, J Am Coll Cardiol, 2003;42: 2125–7.
    Crossref | PubMed
  14. St John Sutton MG, Plappert T, Abraham WT, et al., Effect of cardiac resynchronization therapy on left ventricular size and function in chronic heart failure, Circulation, 2003;107: 1985–990.
    Crossref | PubMed
  15. Grines CL, Bashore TM, Boudoulas H, et al., Functional abnormalities in isolated left bundle branch block. The effect of interventricular asynchrony, Circulation, 1989;79:845–53.
    Crossref | PubMed
  16. Bristow MR, Saxon LA, Boehmer J, et al., Cardiacresynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure, N Engl J Med, 2004;350:2140–50.
    Crossref | PubMed
  17. Nelson GS, Berger RD, Fetics BJ, et al., Left ventricular or biventricular pacing improves cardiac function at diminished energy cost in patients with dilated cardiomyopathy and left bundle-branch block, Circulation, 2000;102:3053–9.
    Crossref | PubMed
  18. Leon AR, Abraham WT, Curtis AB, et al., Safety of transvenous cardiac resynchronization system implantation in patients with chronic heart failure: combined results of over 2,000 patients from a multicenter study program, J Am Coll Cardiol, 2005;46: 2348–56.
    Crossref | PubMed
  19. Kass DA, Chen CH, Curry C, et al., Improved left ventricular mechanics from acute VDD pacing in patients with dilated cardiomyopathy and ventricular conduction delay, Circulation, 1999;99:1567–73.
    Crossref | PubMed
  20. Bleeker GB, Kaandorp TA, Lamb HJ, et al., Effect of posterolateral scar tissue on clinical and echocardiographic improvement after cardiac resynchronization therapy, Circulation, 2006;113:969–76.
    Crossref | PubMed
  21. Rabkin DG, Cabreriza SE, Curtis LJ, et al., Load dependence of cardiac output in biventricular pacing: right ventricular pressure overload in pigs, J Thorac Cardiovasc Surg, 2004;127:1713–22.
    Crossref | PubMed
  22. Mair H, Sachweh J, Meuris B, et al., Surgical epicardial left ventricular lead versus coronary sinus lead placement in biventricular pacing, Eur J Cardiothorac Surg, 2005;27:235–42.
    Crossref | PubMed
  23. Doll N, Opfermann UT, Tastan AJ, et al., Facilitated minimally invasive left ventricular epicardial lead placement, Ann Thorac Surg, 2005;79:1023–5.
    Crossref | PubMed
  24. DeRose JJ, Ashton RC, Belsley S, et al., Robotically assisted left ventricular epicardial lead implantation for biventricular pacing, J Am Coll Cardiol, 2003;41:1414–19.
    Crossref | PubMed
  25. Berberian G, Cabreriza SE, Quinn TA, et al., Left ventricular pacing site-timing optimization during biventricular pacing using a multi-electrode patch, Ann Thorac Surg, 2006;82:2292–4.
    Crossref | PubMed