Thoracoscopic right atrial access for septal lead implantation: a novel minimally invasive technique (case report).

Background: Transvenous lead implantation remains the standard of cardiac pacing; however, alternative strategies are required in patients with limited or absent venous access. Video-assisted thoracoscopic surgery (VATS) has previously been used for epicardial left ventricular lead placement when transvenous approaches fail. Direct thoracoscopic access to the right atrium for endocardial septal pacing has not been previously described. We report a novel, minimally invasive technique allowing right atrial access and implantation of a septal pacing lead targeting the left bundle branch (LBB) area. Case summary: A 67-year-old patient with heart failure with reduced ejection fraction and LBB block was referred for cardiac resynchronization therapy. Conventional transvenous CRT implantation was unsuccessful due to bilateral subclavian venous stenosis and unsuitable coronary sinus lead positioning with high pacing thresholds and phrenic nerve stimulation. Surgical epicardial lead placement was considered high risk because of extensive intrathoracic adhesions following previous oesophageal surgery. A hybrid thoracoscopic approach was therefore pursued. Under general anaesthesia with single-lung ventilation, three 5 mm thoracoscopic ports were inserted on the right anterior thorax. After pericardial opening, a purse-string suture was placed on the right atrium, allowing introduction of a 7-9 Fr sheath using the Seldinger technique. Under fluoroscopic and electrophysiologic guidance, a pacing lead was advanced and positioned in the LBB area. Satisfactory electrical parameters were achieved. Postoperative recovery was uneventful, and device interrogation at follow-up demonstrated stable lead parameters and effective ventricular pacing. Discussion: Thoracoscopic right atrial access may represent a feasible minimally invasive strategy for septal lead implantation in patients without conventional venous access. This hybrid surgical-electrophysiological technique allows direct atrial visualization while enabling endocardial conduction system pacing. Although this initial experience demonstrates technical feasibility and procedural safety, further experience and long-term follow-up are required to determine the reproducibility and durability of this approach.