Ann Thorac Surg 1999;68:1426-1427
© 1999 The Society of Thoracic Surgeons
How To Do It
Pectoral implantation of single-lead implantable cardioverter-defibrillators in patients without transvenous access
Hormoz Mehmanesh, MDa,
Robert Bauernschmitt, MDa,
Rüdiger Lange, MDa
a German Heart Center, Munich, Technical University of Munich, Munich, Germany
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Abstract
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With the introduction of the single-lead "Active-Can" implantable cardioverter-defibrillators, the implantation of the internal defibrillators has become a technically easy procedure. With these systems lowest defibrillation thresholds are achieved with a very low complication rate. For patients with thrombosis of both subclavian veins, however, a transvenous implantation technique is not possible. These patients are still equipped with epicardial patch electrodes. This article describes an alternative technique for implantation of this system in such patients, eliminating the need for epicardial patches and related complications.
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Introduction
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The pectoral implantation of the single-lead "Active-Can" implantable cardioverter-defibrillators (ICD) is a short and easy surgical procedure. Very low defibrillation thresholds (DFTs) are achieved with these devices, which have to be implanted through a transvenous access. However, a number of patients, especially those with multiple central venous catheters or with persistent pacing leads, present with thrombotic occlusion of both subclavian veins. The incidence of subclavian vein thrombosis after recurrent or long-term central venous catheterization is reported to be in the range of 16% and 61% [1, 2]. As for optimal DFTs, the "Active-Can" system is positioned under the left pectoral muscle and the electrode is placed in the right ventricle through the subclavian vein. Patients without transvenous access require epicardial patches instead. Regarding the implantation of epicardial patches, many complications have been reported, such as patch crinkling and dislodgement [3], sympathetic neural dysfunction [4], chronic pericarditis and pericardial constriction [5, 6] and complicated redo procedures. To avoid epicardial patches in patients without transvenous access, we describe an alternative way to implant an "Active-Can" system in such patients.
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Technique
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After a right anterolateral "mini-thoracotomy" with a 8-cm incision in the fourth intercostal space, the pericardium is incised over the right atrial appendage. A pursestring suture is positioned over the tip of the right atrial appendage, secured with a tourniquet and the right ventricular lead is then introduced through the tap incision. The lead is then positioned in the right ventricle (Fig 1). After obtaining the electrophysiologic measurements, determining the pacing and sensing capabilities of the lead position, the purse suture is closed. The incision of the pericardium is also closed. After a 6-cm long infraclavicular incision in front (parallel to the left clavicle) a subpectoral pocket is prepared. A long half-curved clamp is tunneled from the subpectoral pocket under the left pectoral muscle to the left sternal edge. Then the thorax is penetrated above the second rib and at least 2 cm away from the sternal edge (to avoid injuries to the left internal mammary artery) and the distal end of the lead is externalized. For this maneuver both lungs are collapsed to avoid a pneumothorax. After the determination of the DFTs, the chest is closed.
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Fig 1. Alternative endocardial implantable cardioverter-defibrillator implantation technique in patients without venous access.
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Comment
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Epicardial patch electrodes induce scar formation and adhesion of the pericardium with the epicardium with potential subsequent long-term complications. The new "Active-Can" ICDs, which are implanted on the left pectoral side, have shown a low DFT with a single lead. Patients with highly compromised left ventricular function, who have no venous access because of thrombosis of both subclavian veins, are in general equipped with an epicardial defibrillator system. The described procedure is a simple and reliable alternative. The electrophysiologic parameters remain stable and there is no alteration of the defibrillation capabilities. The technique was first performed in a 58-year-old female patient suffering from recurrent ventricular tachycardia, based on an ischemic cardiomyopathy, without any venous access to implant a transvenous ICD. Angiographic examination of the patient showed a thrombosis of the subclavian vein on both sides with sufficient venous collateralization. In this patient a median sternotomy was performed to implant an epicardial ICD, in case of failure of this new technique. Because this procedure was successful, a right lateral "mini-thoracotomy" was used in the next patient to perform the procedure. Although in the follow-up of the patients (15 ± 2 months) no complications were seen, such as lead dislodgement, lead fracture, or wound problems, possible complications of the technique are a pneumothorax or an injury to the left internal mammary artery. The electrophysiologic parameters and the DFTs remained stable. Therefore, we suggest using this technique in patients without venous access for an endocardial ICD implantation.
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References
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Kearns P.J., Coleman S., Wehner J.H. Complications of long arm catheters. JPEN J Parenter Enteral Nutr 1996;20:20-24.[Abstract/Free Full Text]
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Hurlbert S.N., Rutherford R.B. Primary subclavian-axillary vein thrombosis. Ann Vasc Surg 1995;9:217-223.[Medline]
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Molina J.E., Benditt D.G., Adler S. Crinkling of epicardial defibrillator patches. J Thorac Cardiovasc Surg 1995;110:258-264.[Abstract/Free Full Text]
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Rigden L.B., Mitrani R.D., Wellman H.N., Klein L.S., Miles W.M., Zipres D.P. Defibrillation shocks over epicardial patches produce sympathetic neural dysfunction in man. J Cardiovasc Electrophysiol 1996;7:398-405.[Medline]
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Chevalier P., Moncada E., Canu G., et al. Symptomatic pericardial disease associated with patch electrodes of the automatic implantable cardioverter defibrillator. Pacing Clin Electrophysiol 1996;19:2150-2152.[Medline]
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Le Tourneau T., Klug D., Lacroix D., Kacet S., Lekieffre J. Late diagnosis of pericardial constriction associated with defibrillator patches and deformation of the left ventricle. J Cardiovasc Electrophysiol 1996;7:539-541.[Medline]
Accepted for publication June 4, 1999.
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Abstract
Introduction
