Ann Thorac Surg 2001;71:1382-1383
© 2001 The Society of Thoracic Surgeons
How to do it
Implantation of cardioverter device in young children: the perirenal approach
Mark G. Hazekamp, MDa,
Nico A. Blom, MDb,c,
Paul H. Schoof, MDa,
Martin J. Schalij, MDc,
Robert A.E. Dion, MDa
a Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
b Department of Pediatric Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
c Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
Accepted for publication June 5, 2000.
Address reprint requests to Dr Hazekamp, Afdeling Thoraxchirurgie D6-S, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands
e-mail: mhazekamp{at}thorax.azl.nl
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Abstract
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Placement of Implantable cardioverter devices in young children is complicated because of the relatively large size and heavy weight of these devices. A technique is described where the device is implanted in the left perirenal space while an endovascular lead is used instead of an epicardial patch electrode.
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Introduction
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Only a small percentage of implantation of Implantable cardioverter defibrillators (ICD) is performed in patients under the age of 20 years [1]. In young children, specific problems are encountered related to body size, physical activity, and growth, which influence the choice of leads and the implant site of generator. The majority of ICD implantations in small children have been performed with epicardial patch electrodes and generators placed in the abdomen. We describe a technique for implantation of a unipolar defibrillating system in small children using the left perirenal space as a pocket for the generator (Fig 1).
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Fig 1. Implantable cardioverter defibrillator battery in left perirenal space with an endovascular lead inserted through the left subclavian vein. Generous loops are left to allow growth.
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Technique
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The child is positioned on his/her right side. The back of the patient is positioned near to the edge of the table. The access to the left flank is improved by positioning a towel under the patient’s right loin. The exposure is similar to the one that is used for exposure of the kidney by a lumbotomy approach. The left flank should be extended maximally. The lower ribs on the left side must be easily palpable. The left arm is wrapped in sterile drapes so that the arm can be moved for better access to puncture the left subclavian vein. After desinfection and draping, the left subclavian vein is punctured. With the aid of fluoroscopy, the lead is placed in the right ventricular apex and a loop is left in the atrium to allow growth.
A small subcostal incision is made 1 cm below the 12th rib and slightly anterior to the erector spinae muscle (Fig 2). Care should be taken not to mistake the 11th rib for the 12th one, as this may lead to inadvertently opening the pleural space. The muscle layers are split: first, the m. latissimus dorsi, then the external and internal oblique muscles, and, finally, the transverse abdominal muscle. The 12th intercostal nerve will usually be encountered beneath the internal oblique muscle layer and should be carefully preserved. Following opening of the muscle layers, the perirenal fascia is opened and a pocket for the ICD battery is created.
The lead is tunneled from the left prepectoral area to the retroperitoneal perirenal pocket and connected to the ICD. Migration of the device is made impossible by tying the ICD with a nonabsorbable suture to the 12th rib. Pacing, sensing, and defibrillation thresholds are tested, and the wound is closed in layers.
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Comment
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The above-mentioned technique was used in our institution for ICD implantation in a 4-year-old girl (weight 14 kg, length 103 cm) with a familial type of polymorphic ventricular tachycardia. Despite treatment with beta-blockers and calcium antagonists, recurrent syncopes occurred and she was resuscitated prior to admission. The ventricular arrhythmia was successfully treated with Flecainide and the ICD was implanted as a backup for drug failure. We used an endocardial right ventricular defibrillation electrode, Medtronic 6936, 75 cm of length, and an active can generator, Medtronic 7229 GEM II VR (Medtronic, Inc, Minneapolis, MN). The R-wave amplitude was 17 mV, the pacing threshold 0.7 V at 0.5 ms with an impedance of 693 Ohm, and the defibrillation threshold was 12 J. The postoperative course was uneventful and, after testing, she was sent home in good clinical condition. No events occurred during short-term follow-up of 6 months.
In small children requiring ICD therapy, specific problems are encountered. In the first place, a choice has to be made between endocardial leads versus epicardial patch electrodes. The majority of ICD implantations in young children have been performed with epicardial patch electrodes. Although epicardial systems are effective in both children and adults, the perioperative morbidity is higher as compared to transvenous implantations, and complications such as high defibrillation thresholds, pericardial effusion, patch erosion, formation of fibrous tissue, and constrictive pericarditis are not uncommon [1–5]. We therefore prefer to use endocardial ICD leads, even in younger children, taking into account future problems such as vein occlusion and difficult lead removal. Currently, the smallest diameter of an endocardial ICD lead is 7.8 Fr and the length of the defibrillation coil is 5 cm. Relative to the size of the heart and the veins, it is possible to place this lead in children with a minimal weight of 12 to 15 kg, providing that a loop is left in the right atrium to allow growth.
Another problem of pediatric ICD implantation is where to place the relatively large and heavy generator. In young children, subpectoral or preperitoneal placements are likely to cause skin erosion, and most generators are therefore placed in the abdomen. However, compression of the viscera and migration of these abdominally placed devices are known to occur [6]. We have demonstrated that placement of an active can ICD generator in the left perirenal, subcostal position is effective and has several advantages. Like others, we have regularly used this approach for pacemaker implantation in neonates and small children [7]. From outside the body, the generator is not visible. Migration of the device is virtually impossible because of the firm attachment to the 12th rib. Several muscular layers overlay the battery, and erosion of the skin will not occur. Compression of viscera is not likely. In our experience, replacement of perirenally placed generator is as easy as replacement of a preperitoneal or subpectoral device. Retroperitoneal ICD placement has been reported previously as a solution for an infected device in an adult [8]. No data are available concerning active can ICD in the perirenal region. In theory, the defibrillating treshold (DFT) may be somewhat higher as compared to the DFT in the prepectoral position. We found an acceptable DFT of 12 J in our patient, but it is advisable to test DFT during growth of the child.
In young children requiring ICD implantation, a transvenous approach using the left perirenal space for the active can generator is safe and effective, and avoids many problems related to body size and physical activity.
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References
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Link M.S., Hill S.L., Cliff D.L., Swygman C.A., Foote C.B., Homoud M.K., Wang P.J., Estes N.A.M., III, Berul C.I. Comparison of frequency complications of implantable cardioverter-defibrillators in children versus adults. Am J Cardiol 1999;83:263-266.[Medline]
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Singer I., Calzada N., Austin E.H., 3rd Patch migration: a serious late complication of thoracotomy lead systems. PACE 1998;21:2616-2620.
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Chevalier P., Moncada E., Canu G., Claudel J.P., Bellon C., Kirkorian G., Touboul P. Symptomatic pericardial disease associated with patch electrodes of the automatic implantable cardioverter defibrillator: an underestimated complication?. PACE 1996;19:2150-2152.
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Chitkara V.K., Vlay S.G. Erosion of internal cardioverter defibrillator pocket and migration of pulse generator into the peritoneal cavity. PACE 1996;19:1528-1529.
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Hafez A., Conso J.F., Belhaj M., Planché C., Binet J.P. Perirenal space implantation of permanent cardiac pacemakers in infants and small children. Thorac Cardiovasc Surg 1983;31:101-104.[Medline]
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DeFilippi V.J., Gottlieb L., Bump T., Ferguson M.K. Retroperitoneal placement of an ICD generator: a solution for a difficult problem. PACE 1996;19:130-131.
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Abstract
Introduction
