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Original Articles: Pediatric Cardiac

Novel Minimally Invasive, Intrapericardial Implantable Cardioverter Defibrillator Coil System: A Useful Approach to Arrhythmia Therapy in Children

^a Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
^b Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina

Accepted for publication January 7, 2009.

^_* Address correspondence to Dr Hsia, Cardiothoracic Surgery, Medical University of South Carolina, 96 Jonathan Lucas St, CSB 409 Charleston, SC 29425 (Email: hsiaty{at}musc.edu).

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.

Background: Current approaches to implantable cardioverter defibrillator (ICD) implantation in children remain challenging. Transvenous access may be limited due to patient size or anatomy, while epicardial patches require sternotomy or thoracotomy. We present an alternative approach; minimally invasive placement of a transvenous ICD coil within the pericardial space with active fixation.

Methods: Between August 2005 and October 2008, 7 children meeting indications for ICD therapy for ventricular tachyarrhythmias underwent intrapericardial placement of an ICD coil system. Median age was 5 years (range, 1 to 17), weight was 14 kg (range, 8 to 46), and 4 patients weighed less than 20 kg. The ICD system was composed of a single or dual defibrillation coil, an active can, and either ventricular or dual chamber epicardial sense-pace leads. All implantations were performed through a small subxiphoid incision and pericardial window without sternotomy. The coil lead was actively fixated in the transverse sinus under fluoroscopic guidance, and the generator placed in a subrectus pocket in the upper abdomen through the same incision.

Results: There were no perioperative complications, and no early or late deaths. All implants had acceptable defibrillation energies (range, 5 to 15 J) that were successfully tested intraoperatively, and none required energy increase or lead revision during follow-up (range, 1 to 39 months; median, 20 months). Impedance between the active can and the defibrillation coil remained stable in all. There were no inappropriate discharges. Thirty-six successful ICD discharges in 4 patients were recorded. Two patients underwent subsequent orthotopic heart transplantation and ICD system removal.

Conclusions: Intrapericardial placement of an ICD coil system can be safely and successfully carried out through a minimally invasive subxiphoid approach in small infants and children. This novel ICD configuration demonstrates excellent performance, and provides a particularly efficacious approach to ventricular tachyarrhythmia therapy in pediatric patients.