Robotic-Assisted Left Ventricular Epicardial Lead Placement in Patients With Prior Sternotomy.

Background: Cardiac resynchronization therapy (CRT) improves activity tolerance and slows decline in chronic heart failure patients with left ventricular (LV) dysfunction. Traditionally, biventricular lead-based pacing devices or defibrillators are placed intravenously, although some patients require surgical epicardial LV lead placement due to vascular anatomic abnormalities, endocardial fibrosis, or high risk for bacteremia. In patients with prior sternotomy, epicardial lead placement through a thoracotomy, despite a comparatively larger incisional burden, is often preferred over thoracoscopy given the presence of dense adhesions. Approaches that minimize chest wall dissection, however, may allow more patients to safely undergo CRT. This study describes our experience with robotic-assisted LV lead placement in patients with a prior sternotomy. Methods: A single-institution, retrospective review was conducted of consecutive patients with a prior sternotomy referred for surgical epicardial lead placement between January 2018 and July 2023. Results: The analysis included 6 patients with a mean age of 75 years. All leads were placed successfully with a robotic-assisted approach. One patient required conversion to thoracotomy due to significant mediastinal adipose tissue burden. The median length of stay was 2 days. Mortality at 30 days was 0%. One patient sustained unilateral phrenic nerve injury, and a wound infection developed in 1 patient that required subsequent CRT device explant. Conclusions: Robotic LV lead placement is feasible in patients with prior sternotomy. Despite significant comorbidities, lengths of stay and perioperative complications were acceptable. Patients with relative contraindication to epicardial LV lead placement, such as those with a prior sternotomy, may benefit from a robotic-assisted approach.