Video-assisted thoracoscopic epicardial pacemaker implantation: a Colombian case series
Highlight box
Key findings
• Video-assisted thoracoscopic surgery (VATS) epicardial pacemaker placement is feasible alternative to transvenous pacing offering a less invasive approach and less manipulated mediastinum for patients deemed too fragile for a full sternotomy.
What is known and what is new?
• In patients needing cardiac resynchronization therapy and pacing leads with poor vascular access or with infected devices, a VATS approach can be an alternative. Patients having failure attempts to access the coronary sinus through percutaneous approaches can also benefit from a VATS technique.
• Placement of epicardial pacemakers through VATS has not been published widely. Here we present a three-institution experience in Colombia with ten patients.
What is the implication, and what should change now?
• VATS epicardial pacemaker placement is not only a feasible alternative to transvenous pacing that offers a less invasive approach and less manipulated mediastinum, however, it should start becoming a strong part of the surgical option and arsenal for patients deemed too fragile for a full sternotomy.
Introduction
In patients needing cardiac resynchronization therapy (CRT) and pacing leads with poor vascular access or with infected devices, a video-assisted thoracoscopic surgery (VATS) approach can offer an excellent alternative to standard transvenous pacing (1,2). Additionally, patients having failure attempts to access the coronary sinus through percutaneous approaches can benefit from a VATS technique (1,2). Advances in VATS in Colombia have progressed during the years (3-10). Today, minimally invasive approaches for both cardiac and thoracic surgery have been made standard in many clinics throughout the country. Cardiothoracic procedures performed using minimally invasive approaches include VATS hemi-stellectomies for electrical storms, VATS pleurodesis, VATS cardiac trauma management and even valve repairs through peri-areolar techniques (3-10). Placement of epicardial pacemakers through VATS however has not been published widely (1,2,11-14). Here we present a three-institution experience in Colombia with ten patients. We present this case in accordance with the CARE reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-25-26/rc).
Case presentation
Between 2019 and 2024, ten (N=10) patients requiring permanent epicardial left ventricular (LV) pacemaker leads were taken to a video-assisted thoracoscopic (VATS) epicardial pacemaker placement at three centers in Colombia. There were eight (N=8) male patients and two (N=2) female patients. Mean age was 59.6 years and mean left ventricular ejection fraction (LVEF) was 43%. Four patients (N=4) had previously manipulated subclavian veins due to multiple interventions and previously dialysis catheters. Five patients (N=5) had multiple failed attempts by the electrophysiology department to access the coronary sinus. One patient (N=1) had a tricuspid bio-prosthetic endocarditis compromising the lead. All these patients requiring epicardial lead placement as the las resort option were considered for the VATS procedure. All were included in this series and none were excluded. Institutional database was searched and reviewed. Due to health insurance matters, some long-term lead reading data were not retrievable as a result of changed follow-up centers. Patient characteristics are outlined in Table 1. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this case series and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Table 1
| Patient No. | Age (years) | Sex | Condition | Indication | Complications | LVEF (%) | Threshold (volts) at implant & at 30 days | Impedance (ohms) at implant & at 30 days |
|---|---|---|---|---|---|---|---|---|
| 1 | 64 | M | Complete AV block | No vascular access—subclavian vein thrombosis | None | 50 | 1.0; 0.8 | 435; 460 |
| 2 | 56 | M | Dilated cardiomyopathy | LV electrode for CRT† | None | 30 | 1.2; 1.0 | 520; 530 |
| 3 | 58 | F | Dilated cardiomyopathy | LV electrode for CRT† | None | 32 | 0.9; 0.8 | 560; 540 |
| 4 | 93 | M | Complete AV block | No vascular access—device infection | None | 48 | 1.0; 0.9 | 520; 480 |
| 5 | 62 | M | Dilated cardiomyopathy, previous aortic arch replacement, Thoraflex + Bio-Bentall | No vascular access—section of the innominate vein | None | 45 | 1.3; 1.2 | 450; 460 |
| 6 | 18 | M | Dilated cardiomyopathy | LV electrode for CRT† | None | 18 | 1.4; 1.2 | 484; 500 |
| 7 | 64 | M | Complete AV block | No vascular access—subclavian vein thrombosis | None | 60 | 1.0; 0.8 | 560; 540 |
| 8 | 72 | F | Dilated cardiomyopathy | LV electrode for CRT† | None | 32 | 1.3; 1.1 | 490; 520 |
| 9 | 64 | M | Complete AV block | No vascular access—subclavian vein thrombosis | None | 60 | 0.8; 0.8 | 540; 530 |
| 10 | 45 | M | Complete AV block | Presence of tricuspid valve bioprosthesis (due to endocarditis) | None | 55 | 1.6; 1.3 | 530; 560 |
†, in the cases of patients with CRT, technical and anatomical difficulty made electrode placement in the coronary sinus impossible for the electrophysiology team. AV, atrioventricular; CRT, cardiac resynchronization therapy; F, female; LV, left ventricle; LVEF, left ventricular ejection fraction; M, male.
Surgical technique
Patients are placed in supine decubitus with their left arm extended. General anesthesia is applied using a single lumen orotracheal tube without single-lung exclusion (Figure 1A). A three-port VATS approach is used with 1; 2 cm incisions. Ports are placed at the left 5th intercostal (IC) space midaxillary line, 2nd IC space at the anterior axillary line and at the 5th IC space at the midclavicular line (Figure 1B,1C). A 30-degree thoracoscopic lens is used and 10 mmHg intrapleural CO2 pressure is applied to achieve partial ipsilateral lung collapse (Figure 1D). The pericardium is opened to 5 cm in length anterior to the previously identified phrenic nerve using an ultrasonic dissector (Figure 2A). The posterolateral myocardial region between the diagonal and marginal arteries is identified. A Greatbatch Medical Myopore® sutureless myocardial bipolar pacing lead is used. The lead is inserted and twisted into the myocardial wall and the hatchet is released using the device’s trigger system (Figure 2B). Stability is tested by performing a gentle traction to confirm lead fixation. Bleeding at insertion site is minor and does not require intervention. Sensitivity, threshold and impedance are checked and confirmed. Electrode leads are tunneled and externalized in the left anterior subcutaneous chest pocket (Figure 2C,2D). Electrode and lead function are verified. A single chest tube is placed. Surgery time was an average of 65 minutes and patients are extubated in the operating room. Median impedance at surgical insertion and at 30 days were 520 and 525 ohms, respectively. Median threshold at surgical insertion and at 30 days were 1.1 and 0.95 volts, respectively. Chest tubes are removed at postoperative day 1. Median intensive care unit (ICU) stay is 2 days and one additional day in the general ward before discharge. Follow-up is conducted by the electrophysiology department. To date no patients required conversion to open surgery.
Discussion
In cases of poor or absent vascular access due to multiple previous vascular manipulations, device infections and difficulty placing leads into the coronary sinus, a VATS approach is a viable option (1,2,11-14). Permanent Pacemaker placement for adults and older children is preferably via the transvenous route (1,2). It has the advantage of lower pacing threshold, higher impedance, an extended battery life, and a comparatively less invasive approach (11-14). However, for infants and younger children this is not suitable due to their small size, low venous capacitance and the complex venous anatomy associated with some congenital heart disease (11-14). It has been recommended that the epicardial pacing should be used for children ≤15 kg. The epicardial pacemaker placement is also recommended for adults with systemic venous anomalies, functional single ventricle and mechanical tricuspid valve (11-14). However, there is a higher incidence of lead failure (~3-folds) and lesser durability when compared to the endocardial pacing (11-14). Traditionally, placement of epicardial leads follows various approaches, ranging from thoracotomy, partial sternotomy, subcostal, axillary, and the subxiphoid route (11-14). A study by Kim et al. showed high level of effectiveness and long-term safety outcome in the use of VATS epicardial LV lead implants for patients with previous implant failure and late dislodgement of endocardial leads (12). Though, the open chest (full sternotomy or standard thoracotomy) and VATS both offer direct visual control, which is required for appropriate placements of the LV leads at the pacing site: the open chest approach is with a longer hospital stay time, larger scar risk and post-operative pain compared to the VATS (11-14). With thoracotomy there is the tendency for an anterior placement of the leads, which is with more fails at ventricular resynchronization compared to the VATS that allows for a more posterior lead placement (11-14). A study by Nellis et al. showed that the major challenges encountered for the “sew on” lead placement was the limited work field size and the thoracoscopic expertise of the operating surgeon (1). Issues of concern with the VATS epicardial pacemaker placement include, the general anesthetic risk of single lung ventilation in patients with LV systolic dysfunction, However, in the study by Kim et al., all the patients with LV systolic dysfunction (LVEF of 18; 35%) showed good tolerance for general anesthesia (12). This is the first Colombian series and shows that this approach is a viable option in middle-resource settings.
Conclusions
VATS epicardial pacemaker placement is feasible alternative to transvenous pacing offering a less invasive approach and less manipulated mediastinum for patients deemed too fragile for a full sternotomy. Additionally, hospital stay is kept to a minimum along with non-inferior device function.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-25-26/rc
Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-26/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-25-26/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this case series and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Nellis JR, Alsarraj MK, Sauer JS, et al. A minimally invasive approach for atrial and ventricular sew-on epicardial lead placement. JTCVS Tech 2021;7:245-8. [Crossref] [PubMed]
- Said SM. Commentary: Thoracoscopic epicardial permanent pacemaker lead placement: An alternative not a substitute. JTCVS Tech 2021;7:251-2. [Crossref] [PubMed]
- Vinck EE. General thoracic surgery as a subspecialty in Colombia. J Thorac Cardiovasc Surg 2019;157:2542-6. [Crossref] [PubMed]
- Vinck EE. Cardiac surgery in Colombia: History, advances, and current perceptions of training. J Thorac Cardiovasc Surg 2020;159:2347-52. [Crossref] [PubMed]
- Vinck EE, Rendón JC, Andrade D, et al. Minimally Invasive Cardiac Surgery in Colombia: Evolution and the Impact of International Training. Innovations (Phila) 2021;16:305-9. [Crossref] [PubMed]
- Téllez LJ, Garzón JC, Vinck EE, et al. Video-assisted thoracoscopic cardiac denervation of refractory ventricular arrhythmias and electrical storms: a single-center series. J Cardiothorac Surg 2019;14:17. [Crossref] [PubMed]
- Garzón JC, Edward Vinck E, Carolina Cárdenas D, et al. Video-assisted thoracoscopic iodopovidone pleurodesis for malignant pleural effusions in moderate to high-risk Colombian patients. J Cardiovasc Thorac Res 2020;12:328-33. [Crossref] [PubMed]
- Vinck EE, Ángel EP, Barrios RV, et al. Video-Assisted Thoracoscopy For Penetrating Cardiac Box Injury in Stable Patients. Braz J Cardiovasc Surg 2021;36:550-6. [Crossref] [PubMed]
- Vinck EE, Zapata RA, Tarazona CA, et al. Intercostal Lung Hernias Presenting After Minimally Invasive Cardiac Surgery. Braz J Cardiovasc Surg 2024;39:e20230403. [Crossref] [PubMed]
- Vinck EE, García MM, Rendón JC, et al. Periareolar Cardiac Surgery in Patients With Breast Implants: How to Do It. Innovations (Phila) 2025;20:96-101. [Crossref] [PubMed]
- Stewart S. Placement of the sutureless epicardial pacemaker lead by the subxiphoid approach. Ann Thorac Surg 1974;18:308-13. [Crossref] [PubMed]
- Kim HR, Lim K, Park SJ, et al. Thoracoscopic Implantation of Epicardial Left Ventricular Lead for Cardiac Resynchronization Therapy. J Cardiovasc Dev Dis 2022;9:160. [Crossref] [PubMed]
- Nelson KE, Bates MG, Turley AJ, et al. Video-assisted thoracoscopic left ventricular pacing in patients with and without previous sternotomy. Ann Thorac Surg 2013;95:907-13. [Crossref] [PubMed]
- Navia JL, Atik FA, Grimm RA, et al. Minimally invasive left ventricular epicardial lead placement: surgical techniques for heart failure resynchronization therapy. Ann Thorac Surg 2005;79:1536-44; discussion 1536-44. [Crossref] [PubMed]
Cite this article as: Bucheli VR, Enríquez LE, Negrete A, Gil E, Gómez A, Effiom V, Vinck EE. Video-assisted thoracoscopic epicardial pacemaker implantation: a Colombian case series. Video-assist Thorac Surg 2025;10:30.
