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Ann Thorac Surg 1997;64:1156-1158
© 1997 The Society of Thoracic Surgeons

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Case Report

Simultaneous Use of an Implanted Defibrillator and Ventricular Assist Device

Divisions of Cardiothoracic Surgery and Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama

Accepted for publication April 24, 1997.

	Abstract

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
A left ventricular assist device was placed as a bridge to cardiac transplantation in a 51-year-old man with cardiogenic shock. Placement of the left ventricular assist device occurred 5 years after implantation of an implantable cardioverter/defibrillator. The implantable cardioverter/defibrillator discharged appropriately during ventricular assist device support to terminate episodes of sustained ventricular tachycardia without causing malfunction of the ventricular assist device.

	Introduction

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
The implantable cardioverter/defibrillator (ICD) has proved successful in treating patients with ventricular arrhythmias [1, 2], and has been used as a bridge to cardiac transplantation in patients with recurrent ventricular arrhythmias [2]. Likewise, ventricular assist devices (VADs) are an effective treatment for profound circulatory failure and have been used successfully in patients with ventricular arrhythmias [3–7]. Here we report the simultaneous use of a VAD and an ICD in a patient being bridged to transplantation.

A 51-year-old man was referred to this institution for cardiac transplant evaluation 3 days after acute inferior wall myocardial infarction and hypotension necessitating placement of an intraaortic balloon pump. The patient's medical and surgical history included coronary artery disease with coronary artery bypass grafting 11 years earlier and ICD implantation (CPI Ventak model 1550 pulse generator, CPI model L67 large left ventricular patch electrode, and CPI model A67 small right ventricular patch electrode; CPI [currently Guidant, Inc], St. Paul, MN; and two Cordis model 325-452 rate-sensing electrodes; Cordis, Miami, FL) via left anterolateral thoracotomy 5 years earlier, with ICD replacement 2 years earlier (Medtronic Model 7217; Medtronic, Inc, Minneapolis, MN).

Physical examination on admission showed a sedated, intubated man, with a femoral intraaortic balloon pump set at a counterpulsation rate of 1:1. His systolic blood pressure was 100 mm Hg, the pulmonary capillary wedge pressure was 14 mm Hg, and the cardiac index was 2.2 L • min^{-1 • m-2. He had atrial flutter with 4:1 block, a murmur of mitral regurgitation, and a third heart sound. The remainder of the physical examination was unremarkable with the exception of a well-healed sternotomy and thoracotomy scars and an ICD generator positioned in the left upper abdominal quadrant. Medications included dobutamine, heparin, nitroglycerin, and lidocaine infusions.}

Cardiac catheterization, undertaken 1 day before transfer, showed a patent internal thoracic artery graft to the left anterior descending artery, occlusion of all saphenous vein grafts, an 80% ostial left main coronary artery stenosis, and diffusely diseased native arteries unsuitable for regrafting. The left ventricular ejection fraction was 0.15. Intravenous administration of amiodarone was initiated for multiple sustained episodes of ventricular tachycardia that were terminated by ICD shocks.

The patient's pre-VAD hospital course was marked by bacteremia, bilateral lower lobe pneumonia, intraaortic balloon pump and ventilator dependence, and recurrent episodes of slow ventricular tachycardia (100 to 110 beats/min). Seventeen days after his myocardial infarction, a left VAD (HeartMate IP left VAD; Thermo Cardiosystems Inc, Woburn, MA) was implanted.

Immediately before left VAD insertion, the ICD was deactivated. The ICD defibrillation electrodes had been placed on the pleural aspect of the pericardium overlying the midportions of the left and right ventricles, and the sensing electrodes had been positioned between the ICD patch electrodes so that they lay over the left ventricle. The ICD patch and sensing electrodes were displaced during the procedure when the epicardium was dissected away from the pericardium. The pericardium with its attached defibrillation and sensing electrodes was repositioned over the ventricles after the VAD was in place (Fig 1).

View larger version (58K): [in this window] [in a new window]   Fig 1. . Chest roentgenogram showing left ventricular assist device and implantable cardioverter/defibrillator electrodes.

View larger version (146K): [in this window] [in a new window]   Fig 2. . Lead II electrocardiogram and systemic blood pressure (SBP) tracings before, during, and after implantable cardioverter/defibrillator discharge for sustained ventricular tachycardia. Note the conversion to sinus rhythm and improvement in blood pressure.

	Comment

Top Footnotes Abstract Introduction Comment Acknowledgments References

This patient had two documented ICD discharges that converted sustained ventricular tachycardia to sinus rhythm. Left VAD pumping function was not altered by the ICD shocks. Furthermore, the VAD did not cause electrical artifacts in the sensing circuits of the ICD, there were no inappropriate ICD discharges, and the bradycardia pacing function of the ICD (VVI mode pacing at 60 beats/min) performed properly. After 54 days of circulatory support, the patient successfully received a transplant and the ICD was removed.

Additional observations are required to confirm the ability of other VAD designs to coexist with various ICD configurations, particularly newer ones that use transvenous pacing, sensing, and defibrillation electrodes. Implantable cardioverter/defibrillators can provide a useful function in patients with VADs, particularly in those patients who are supported in an outpatient setting. Placement of an ICD should be considered for patients supported by a VAD who experience sustained ventricular arrhythmias despite pharmacologic and ablative therapy.

	Acknowledgments

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
This work was performed during Dr Holman's tenure as an Established Investigator for the American Heart Association.

We thank Victor L. Poirier, President and CEO of Thermo Cardiosystems, Inc, for his helpful comments on this article.

	Footnotes

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
Address reprint requests to Dr Holman, Department of Surgery, University of Alabama at Birmingham, University Station, Birmingham, AL 35294-0007 (e-mail: wholman{at}holman.cvsr.uab.edu).

	References

Top Footnotes Abstract Introduction Comment Acknowledgments References

 

1. Mirowski M, Reid PR, Mower MM, et al. Termination of malignant ventricular arrhythmias with an implanted automatic defibrillator in human beings. N Engl J Med 1980;30:322–4.
2. Trappe HJ, Wenzlaff P. Cardioverter defibrillator therapy as a bridge to heart transplantation. PACE 1995;18(Part 2):622–31.
3. Farrar DJ, Hill D, Gray LA, Galbraith TA, Chow E, Hershon JJ. Successful biventricular circulatory support as a bridge to cardiac transplantation during prolonged ventricular fibrillation and asystole. Circulation 1989;80(Suppl 3):147–51.
4. Arai H, Swartz MT, Pennington DG, et al. Importance of ventricular arrhythmias in bridge patients with ventricular assist devices. ASAIO Trans 1991;37:M427–8.
5. Geannopoulos CJ, Wilber DJ, Olshansky B. Control of refractory ventricular tachycardia with biventricular assist devices. PACE 1991;14:1432–4.
6. Pennington DG, McBride LR, Kanter KR, et al. Bridging to heart transplantation with circulatory support devices. J Heart Transplant 1989;8:116–23.
7. Holman WL, Roye GD, Bourge RC, McGiffin DC, Iyer SS, Kirklin JK. Circulatory support for myocardial infarction with ventricular arrhythmias. Ann Thorac Surg 1995;59:1230–1.
8. Shepard RB, Epstein AE, Kay GN, et al. Can the heart be chronically paced with electrodes on the pericardial surface? PACE 1992;15(Part 2):2041–5.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Richard B. Shepard William L. Holman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Skinner, J. L. Articles by Holman, W. L. Search for Related Content PubMed Articles by Skinner, J. L. Articles by Holman, W. L.