Single-Port Robotic-Assisted Epicardial Lead Placement for Cardiac Resynchronization Therapy

Abstract

We present a case demonstrating the novel use of the da Vinci SP (single-port) robotic platform (Intuitive Surgical) in cardiac surgery. A 69-year-old man with ischemic cardiomyopathy and failed endovascular cardiac resynchronization therapy defibrillator lead placement underwent successful robotically assisted left ventricular epicardial lead implantation through a 4-cm minithoracotomy. The da Vinci SP system enhanced visualization and dexterity, thus allowing for precise lead placement with minimal invasiveness. The patient recovered uneventfully and remained stable at follow-up. This case highlights the feasibility and potential advantages of single-port robotic-assisted cardiac procedures in select patients.

Robotic-assisted cardiac surgery has seen significant growth and technical improvements since its advent in the 1980s and is transforming the field of cardiothoracic surgery. It provides several advantages, including improved 3-dimensional visualization, great dexterity with articulated instruments, tremor reduction, and the ability to scale down hand movements, features that make it ideal for complex procedures. A nationwide study of robotic-assisted cardiac cases demonstrated a shorter length of stay, lower mortality, and fewer complications for all operation types compared with nonrobotic surgery.¹

The da Vinci SP (single-port) system is the newest iteration of the commonly used surgical platform by Intuitive Surgical. It uses an articulating 3-dimensional endoscope and 3 wristed instruments through a single port. It has already been established in certain surgical fields such as urology, but its applicability in cardiac surgery has yet to be reported. The study participant provided informed consent before study enrollment.

We report the case of a 69-year-old man with a history of remote coronary artery bypass grafting and symptomatic ischemic cardiomyopathy with interventricular delay who presented for consideration of cardiac resynchronization therapy (CRT). An initial attempt at endovascular placement was unsuccessful for anatomic reasons. Therefore, a surgical referral was made for epicardial lead placement. Given his previous coronary revascularization, older age, and relative frailty, a less invasive approach was advised. Left ventricular epicardial lead placement through a robotically assisted approach was recommended. We opted to use a single-port approach. The decision rationale was to minimize the risk of previous adhesion lysis and a patent left internal mammary artery. Given that a small minithoracotomy was going to be performed, we opted to use the new da Vinci SP platform.

With the patient’s left lung deflated, a 4-cm left anterior thoracotomy was made in the fourth intercostal space, and the left pleura was entered. Adhesions were taken down, and a small Alexis soft tissue retractor (Applied Medical) was inserted, followed by further lysis of adhesions. The da Vinci SP robot was then brought into the surgical field and docked. With the assistance of the robot, the pericardium was entered. Two pericardial traction sutures were placed and tunneled through the superior and inferior intercostal spaces. We then proceeded with placement of epicardial Medtronic CapSure Epi MP bipolar steroid-eluting leads onto the basal anterior surface of the left ventricle (Figure). These leads were secured with 4-0 Cardionyl suture (Peters Surgical) by using 2 needle drivers (Video).

Figure.

Robotic-assisted single-port cardiac resynchronization therapy electrode placement.

We then reopened the CRT defibrillator generator pocket and removed the generator, with care taken not to damage the leads. The newly implanted epicardial lead was tunneled into this pocket and connected to the generator (Dynagen CRT-D, Boston Scientific). This maneuver was performed by entering the chest from the pocket incision and grasping the leads from within the chest cavity. The device was then interrogated and found to be functioning appropriately.

The patient’s postoperative course was uneventful. He was extubated at the completion of the procedure and remained hemodynamically stable throughout his recovery. He was discharged home on postoperative day 3, after he had been medically optimized from a heart failure and hemodialysis perspective. He was seen in follow-up clinic 2 weeks after the epicardial lead insertion and continued to do well, with good wound healing and minimal incisional pain.

Comment

Use of CRT to improve outcomes in patients with heart failure and interventricular delay is well established. In cases where endovascular implantation is not possible because of anatomic restrictions, an open surgical approach is possible, and it was demonstrated to make no difference in echocardiographic or clinical outcomes.² With the potential benefit of less postoperative pain, better wound healing, improved cosmesis, shorter length of stay, and a decreased conversion rate when compared with thoracoscopic surgery, as well as increased dexterity and visualization, robotic-assisted surgery is a favorable surgical approach.³ Although thoracoscopic surgery is associated with a shorter learning curve and lower equipment costs, we opted to use the robotic platform given the limited need for lysis of adhesions and the platform’s single-port capability and concomitant dexterity.⁴ By leveraging existing resources and expertise, we were able to effectively address any potential concerns related to prolonged operative times and higher costs usually associated with robotic-assisted surgery.⁵

Recent advancements in single-port robotic-assisted technology demonstrate a new frontier in the surgical fields, with proven safety and efficacy. Therefore, we believe that cardiac surgery should participate in the development of this technology. This case highlights the potential of the da Vinci SP robotic platform in cardiac surgery, thereby suggesting a promising avenue for minimally invasive approaches in select patients and laying the groundwork for future applications and studies in more complex cases.