Thoracoscopic Right Atrial Access for Septal Lead Implantation: A Novel Minimally Invasive Technique

Conventional transvenous pacing is standard care; however, patients with limited venous access often face a therapeutic dead end. The authors present a novel, minimally invasive thoracoscopic technique for right atrial access and septal lead implantation, targeting the left bundle branch (LBB) area—a solution that has not been previously described.

The case involved a patient with heart failure and left bundle branch block who could not undergo standard transvenous or epicardial lead placement due to bilateral subclavian stenosis and extensive post-surgical adhesions. Using three 5 mm thoracoscopic ports, the pericardium was opened, a purse-string suture was placed on the right atrium, and a pacing lead was advanced across the atrial septum under fluoroscopic and electrophysiologic guidance.

The procedure was completed safely, resulting in an uneventful recovery and excellent lead function. This approach offers direct atrial visualization, precise lead placement, and minimal surgical trauma, opening a new pathway for patients previously considered ineligible for conventional pacing. With further experience, this technique has the potential to redefine pacing strategies in anatomically challenging or high-risk patients.

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References

1. Kumar V., Nayak P.K., Yadav M.S. et al. Alternate method for endocardial pacemaker lead implantation: a hybrid mini-thoracotomy approach. Indian pacing electrophysiol. 2021,21(3):178-181 https://doi.org/10.1016/j.ipej.2021.01.007 
2. Navia J.L., Atik F.A., Grimm R.A. et al. Minimally invasive left ventricular epicardial lead placement: surgical techniques for heart failure resynchronization therapy. Ann Thorac Surg, 2005, 79(5): 1536-44. https://doi.org/10.1016/j.athoracsur.2004.10.041 

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