Reverse remodeling with robotic surgical resynchronization

Background: Advanced heart failure (HF) often results in progressive left ventricular (LV) dilation with a concomitant reduction of contractile function, referred to as “cardiac remodeling.” Cardiac resynchronization therapy (CRT) with biventricular (BiV) pacing has been shown to improve HF clinical status, however effective transvenous CRT is dependent upon inconsistent coronary venous anatomy and access. Minimally invasive surgical epicardial LV lead implantation, targeting the most advantageous region of the LV for effective CRT, has emerged as “rescue therapy” for failed implants. The effect of surgically implanted epicardial LV lead placement via robotics on reverse remodeling has not been previously studied. Methods: 27 consecutive patients underwent surgically implanted epicardial LV lead placement via a robotic system after a failed transvenous attempt. Patients were 71 11 years, 67% male, 66%ischemic, New York Heart Association (NYHA) class 3.2 0.5, and LV ejection fraction (EF) 0.20 0.09. All patients were treated with ACEI and betablockers. Reverse remodeling was assessed by preoperative and postoperative (12 7 mos) 2-dimensional transthoracic echocardiograms. Results: All 27 patients survived to the follow-up echo, at which time, 19 had improved 1 NYHA class. There was a significant decrease in both systolic (s) and diastolic (d) LV internal dimension index (LVIDI): LVIDIs (-5.9 2.2 mm/m2) and LVIDId (-4.2 2.3mm/m2), and an increase in LVEF (7.3 2.6 %). See Figure. Conclusion: This is the first report demonstrating that CRT via surgically implanted epicardial LV lead placement is highly effective in promoting reverse remodeling in severe HF patients. Given these very favorable observations, surgical approach should be explored as first line therapy. Whether surgical vs. transvenous lead placement is superior needs to be evaluated in a prospective randomized trial.