Background Cardiac resynchronization therapy (CRT) using a left ventricular (LV) lead inserted via the coronary sinus (CS) improves symptoms of congestive heart failure (CHF), decreases hospitalizations, and improves survival. An epicardial LV lead is often placed surgically after failed percutaneous attempt, but it is unknown if they offer the same benefits. Objective To determine if patients who receive a surgical LV lead after failed CS lead placement for CRT derive the same benefit as patients with a successfully placed CS lead. Methods A total of 452 patients underwent attempted CS lead insertion. Forty-five patients who had failed CS lead placement and then had a surgical LV lead placed were matched with 135 patients who had successful CS lead placement. Results There were no major differences in preoperative variables between groups. Post-procedure complications of acute kidney injury (26.2% vs. 4.9%, P <0.001) and infection (11.9% vs. 2.4%, P=0.03) were more common in the surgical group. Mean long-term follow-up was 32.4 ± 17.5 months for surgical patients and 39.4 ± 14.8 months for percutaneous patients. At follow-up, all-cause mortality (30.6% vs. 23.8%, P=0.22) and readmission for CHF (26.2% vs. 31.5%, P=0.53) were similar between surgical and percutaneous groups. Improvement in NYHA class (60.1% vs. 49.6%, P=0.17) was similar between surgical and percutaneous groups. Conclusions Surgical LV lead placement offers functional benefits similar to percutaneous placement. This comes with the greater risk of perioperative complications including acute renal failure and infection.

Pain after thoracic surgery has a profound impact on perioperative outcome. Beyond the immediate perioperative period, acute pain contributes to the development of the debilitating chronic pain syndrome. Going forward, both procedural and pharmacologic interventions for acute and chronic pain should be studied in definitive multicenter, well designed randomized clinical trials.

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