Europace Advance Access originally published online on November 30, 2007
Europace 2008 10(1):122-123; doi:10.1093/europace/eum256
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LETTERS
Concerns about the long-term outcome of transseptal cardiac resynchronization therapy: what we have learned from surgical experience: reply
SouthWest Cardiothoracic Centre
Department of Cardiology
Derriford Hospital
Derriford Road
Plymouth
Devon PL6 8DH
UK
Tel/fax: +44 156 677 9429.
E-mail address: bnuta{at}doctors.org.uk
Thank you for offering us the opportunity to clarify some aspects regarding the endocardial LV placement case presentation. The comments by Kassai et al. are in fact entirely relevant and it was not our intention to underestimate the technical difficulties of the procedure or indeed the potential short and long term complications. In fact, we only consider this approach in very symptomatic patients with highly unsuitable coronary sinus veins anatomy and usually after more than one attempt using the conventional method. The other main considerations are a significant surgical risk and patient's strong treatment preference after detailed discussion of all feasible options.
In this particular case, high risk surgery was discussed with the patient and his family who expressed a clear preference to try this technique in order to alleviate some of his marked symptoms and limitations. With this technique of endocardial LV lead placement, in practical terms the only need for surgery would have been either a procedure-related complication or a late complication such as left heart infective endocarditis. The risk attached to the transseptal puncture itself was classed as small, since we are used to crossing the interatrial septum for our regular left atrial ablation procedures in patients with atrial fibrillation. The risk of infective endocarditis was estimated at 0.67% at 1 year1
and we used a combination of antibiotics at implant in line with specialist microbiology advice. Furthermore, if he developed left and right heart infective endocarditis needing cardiothoracic surgery as a result, then he would be estimated to have a survival chance of 67.5 and 50.8% at 5 and 10 years, respectively.2 Yet, his surgical risk with an initial thoracotomy approach was believed to have been significantly higher, primarily in view of his heart failure and general anaesthesia. Without cardiac resynchronization and despite optimal medical treatment, the likelihood is that his symptoms would have continued to deteriorate at an unpredictable pace. Instead, he remains well and his quality of life has improved significantly now more than 1 year after the procedure.
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[1] Klug D, Balde M, Pavin D, et al. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: results of a large prospective study. Circulation (2007) 116:1349–55.
[2] Musci M, Siniawski H, Pasic M, et al. Surgical treatment of right-sided active infective endocarditis with or without involvement of the left heart: 20-year single center experience. Eur J Cardiothorac Surg (2007) 32:118–25.
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