Ann Thorac Surg 2001;72:2125-2127
© 2001 The Society of Thoracic Surgeons
Case report
Successful implantation of a cardioverter defibrillator in an infant
Hiroshi Watanabe, MD*a,
Jun-ichi Hayashi, MDa,
Manabu Haga, MDa,
Masayuki Saito, MDa,
Hiroshi Suzuki, MDb,
Seiichi Sato, MDb
a Department of Thoracic and Cardiovascular Surgery, Niigata University School of Medicine, Niigata, Japan
b Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan
Accepted for publication October 18, 2000.
* Address reprint requests to Dr Watanabe, Department of Thoracic and Cardiovascular Surgery, Niigata University School of Medicine, 1-757 Asahimachi-dori, Niigata City 951-8510 Japan
e-mail: watanabe{at}med.niigata-u.ac.jp
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Abstract
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We report the successful implantation of a cardioverter defibrillator (ICD) in a 12-month-old infant. A single-lead ICD using an epicardial patch and a cathodal pulse-generator titanium shell electrode was very useful for implantation in this infant.
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Introduction
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In adults, implantable cardioverter defibrillators (ICDs) are an accepted and commonly used form of therapy for life-threatening arrhythmias, such as ventricular tachycardia and ventricular fibrillation. However, they are infrequently used in younger patients, particularly in infants [1, 2], and no ICD implantation techniques have been established specifically for use in infants. We report a case of ICD implantation in a 12-month-old infant.
A 6-month-old boy suffered attacks of sudden faintness and cyanosis. His electrocardiogram revealed right bundle-branch block and ST-T elevation in leads V1 and V2. Ambulatory 24-hour Holter monitoring showed 784 repetitive ventricular fibrillations. Echocardiography, magnetic resonance imaging and SPECT thallium imaging revealed nothing abnormal. Repeated episodes of ventricular fibrillation, each lasting a few seconds, were recognized. After these occurred several times, cardiopulmonary resuscitation was performed. His family history included ventricular tachycardia in his paternal grandmother, and sudden infant death of his twin brother during sleep (at age 4 months). Antiarrhythmic drugs, including propranolol, mexiletine, and quinidine, were ineffective in preventing recurrence of ventricular fibrillation. Brugada syndrome was diagnosed, and it was decided to implant a cardioverter defibrillator.
When the patient was 12 months old and weighed 7.8 kg, the operation was performed after informed consent was obtained. A median sternotomy was made to expose the heart, but the heart showed no abnormality. A single small epicardial patch (model 6721S, Medtronic, Inc, Minneapolis, MN) was placed against the inferoposterior wall of the left ventricle, and was fixed to the pericardium using interrupted 4 to 0 braided polyester sutures. The heart was too small for the second patch to be placed on the anterior surface of the right ventricle. A steroid-eluting bipolar lead (model 4968, Medtronic) was implanted on the right ventricular surface. The pacing threshold was 1.1 V at 0.5 ms impulse duration.
The posterior rectus pocket of the generator was then created. A longitudinal incision was made in the left side of the linea alba, and the medial edge of the left rectus abdominis muscle was exposed. The pouch was created by dissecting the plane between the rectus abdominis muscle and the posterior rectus sheath, and the internal oblique fascia was divided by electrocautery at the lateral margin of the rectus sheath to increase the lateral dimension of the pocket beyond that of the rectus sheath itself between the internal oblique muscle and the transverse abdominis muscle [3]. Then, the dissection was continued caudad beneath the costal margin by mobilizing the insertion of the diaphragm in the lower rib cage. The space beneath the costal margin was large enough to accommodate one third of the ICD. An active can device (model 7223Cx, Medtronic) was placed in the pocket, using unipolar defibrillation in a can-epicardial patch configuration (Fig 1). The induced ventricular fibrillation was successfully terminated by biphasic shock at 20 J. After a defibrillation threshold test was carried out, the sternotomy and skin incision were closed carefully (Fig 2). In a follow-up after 6 months, one shock was successfully delivered for ventricular fibrillation.
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Fig 1. Schematic representation of the ICD implantation. A single small epicardial patch was placed posteriorly, and was fixed to the pericardium. A cathodal pulse generator was placed in the posterior rectus pocket, using unipolar defibrillation in a can-epicardial patch configuration.
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Fig 2. Chest roentgenogram after implantation of an epicardial patch and a cathodal pulse generator. (A) anterior-posterior view; (B) lateral view.
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Comment
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Although nonthoracotomy defibrillation lead systems are now frequently implanted in adults, none of the transvenous leads are available for small infants. Our experience suggested that the epicardial approach would be the best in such a patient. In addition, a single-lead ICD [4] using an epicardial patch and a cathodal pulse-generator titanium shell electrode was very useful for implantation in our patient. However, revision of the lead system as the child grows will be necessary, because the surface area of the small epicardial patch may be too small for defibrillation in an adult.
Another complication might be crinkling of the epicardial patch or pericardial constriction by the epicardial patch. Although the incidence of patch crinkling was reported to be relatively high [5], epicardial patch constriction is a rare occurrence that requires removal of the epicardial patch and implantation of a transvenous ICD [6]. Because ICD implantation in an infant has not been reported in the literature, we must follow-up this patient with care.
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References
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Habal S.M., David I.B., Luceri R.M. Simplified subxiphoid placement of implantable cardioverter defibrillators using a posterior rectus pocket. Ann Thorac Surg 1994;57:723-725.[Abstract]
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Bardy G.H., Johnson G., Poole J.E., Dolack G.E., Kudenchuk P.J., Kelso D., et al. A simplified, single-lead unipolar transvenous cardioversion-defibrillation system. Circulation 1993;88:543-547.[Abstract/Free Full Text]
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Molina J.E., Benditt D.G., Adler S. Crinkling of epicardial defibrillator patches: A common and serious problem. J Thorac Cardiovasc Surg 1995;110:258-264.[Abstract/Free Full Text]
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Barrington W.W., Deligonul U., Easley A.R., Windle J.R. Defibrillator patch electrode constriction: An underrecognized entity. Ann Thorac Surg 1995;60:1112-1116.[Abstract/Free Full Text]
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