ABC | Volume 110, Nº5, May 2018

Case Report Silva Surgical epicardial CRT-D implantation Arq Bras Cardiol. 2018; 110(5):490-492 Figure 1 – A) 12-lead ECG before epicardial CRT-D implantation: sinus P waves with dissociated right ventricular epicardial pacing; B) 12-lead ECG after epicardial CRT-D implantation: sequential atrial pacing and biventricular pacing. C) Chest x ray before epicardial CRT-D implantation: 1 Abandoned endocavitary right atrial lead; 2- Abandoned endocavitary right ventricular pacing/defibrillator lead; 3- Abandoned endocavitary left ventricular lead; 4 – Epicardial mono-chamber pacemaker generator; 5 - Epicardial mono-chamber pacemaker lead. D) Intra operatory situs after lead implantation: 1 - Epicardial right atrial lead; 2 – Epicardial right ventricular outflow tract lead; 3- Left ventricular lateral lead; 4- Epicardial anterior defibrillator patch; 5- Epicardial posterior defibrillator patch. E) Intra operatory situs showing lead tunneling to left sided pre pectoral pocket. F) Chest x ray after epicardial CRT-D implantation: 1 Abandoned endocavitary right atrial lead; 2 - Abandoned endocavitary right ventricular pacing/defibrillator lead; 3 - Abandoned endocavitary left ventricular lead; 4 - Epicardial right atrial lead; 5 – Epicardial right ventricular outflow tract lead; 6- Left ventricular lateral lead; 7 - Epicardial anterior defibrillator patch; 8 - Epicardial posterior defibrillator patch; 9 – Epicardial CRT-D generator. CRT-D: cardiac resynchronization and defibrillation; ECG: eletrocardiogram. Complete epicardial CRT-D implantation has been described in patients undergoing on-pump cardiac surgery for other reasons. 7 Minimally invasive surgery using a small thoracotomy or using video-assisted thoracoscopy with or without robotic assistance is well described for LV lead implantation when a percutaneous procedure fails. 8 A complete CRT-D has also been implanted using robotic assistance. 9 Since there is no surgical access to the RV and RA, the RV lead was placed on the anterior wall of the LV and the RA lead in the left atrial appendage. Also, it is not possible to implant a defibrillator patch using this technique, and its availability is scarce. Although there is no cost-effective data regarding minimally invasive LV lead surgical implantation, it is well known that robotic assisted mitral valve repair is associated with greater costs. 10 Conclusion To our knowledge, this is the first report of a complete off‑pump epicardial sequential atrial-biventricular resynchronization and patch defibrillation device implantation requiring a median sternotomy. To clarify the effectiveness and safety of this procedure, more cases and longer-term observation are mandatory. Author contributions Conception and design of the research: Silva GL, Cortez‑Dias N, Sousa J, Nobre A, Pinto FJ; Acquisition of data: Silva GL; Writing of the manuscript: Silva GL, Pinto FJ; Critical revision of themanuscript for intellectual content: Cortez-Dias N, Sousa J, Nobre A. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. 491