Robotically Assisted Lead Implantation for Cardiac Resynchronization Therapy in a Reoperative Patient

History

The patient has an extensive cardiac history, beginning with a myocardial infarction and subsequent coronary artery bypass and three grafts in 1988. In 2002, he underwent a reoperative three-vessel bypass. He was diagnosed with sick sinus syndrome in 2001 that required the implantation of a dual-chamber pacemaker. The device was updated to an implantable cardioversion defibrillator (ICD) in 2002 after he experienced cardiac arrest. He was successfully resuscitated without neurologic sequelae. The prior right ventricular lead was abandoned and capped, and the patient received a dual-coil high-voltage lead. The generator was replaced in 2005 and again in late 2011. On the current admission, the patient had poorly controlled hypertension and worsening heart failure in the setting of chronic right ventricular pacing. Left ventricular ejection fraction had fallen from greater than 55%, 1 year previously, to 31%. The patient experienced progressive dyspnea on exertion.

Current Medications

The patient was taking aspirin 81 mg daily, atorvastatin 80 mg daily, candesartan 16 mg daily, carvedilol 12.5 mg twice daily, dutasteride 0.5 mg daily, niacin 500 mg daily, and spironolactone 25 mg daily.

Physical Examination

• BP/HR: 138/80 mm Hg/70 bpm, regular

• Height/weight: 172.7 cm/82.5 kg

• Neck veins: Not distended

• Lungs/chest: Clear, well-healed sternotomy scar

• Heart: Fourth heart sound (S ₄ ) gallop without murmur

• Abdomen: Soft, without hepatic distention

• Extremities: No edema, well-healed scar from radial artery harvest

Laboratory Data

• Hemoglobin: 14.5 g/dL

• Hematocrit/packed cell volume: 42.5%

• Mean corpuscular volume: 92 fL

• Platelet count: 152 × 10 ³ /µL

• Sodium: 139 mmol/L

• Potassium: 3.7 mmol/L

• Creatinine: 0.9 mg/dL

• Blood urea nitrogen: 17 mmol/L

Electrocardiogram

Findings

The electrocardiogram revealed atrial-sensed ventricular-paced rhythm ( Figure 21-1 ), with a heart rate of 62 bpm and QRS duration of 192 msec.

Sinus bradycardia with underlying left bundle branch block also was seen ( Figure 21-2 ). The heart rate was 59 bpm and QRS duration 132 msec.

Atrial sensing and biventricular pacing were demonstrated on the electrogram ( Figure 21-3 ), with a heart rate of 66 bpm and QRS duration of 138 msec.

Chest Radiograph