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Ann Thorac Surg 2007;84:303-305
© 2007 The Society of Thoracic Surgeons

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How To Do It

Initial Experience With Implantable Cardioverter Defibrillator Systems Using Epicardial and Pleural Electrodes in Pediatric Patients

^a Division of Pediatric Cardiology, University Children’s Hospital Zurich, Zurich, Switzerland
^b Division of Congenital Cardiovascular Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
^c Department of Diagnostic Imaging, University Children’s Hospital Zurich, Zurich, Switzerland

Accepted for publication October 2, 2006.

^_* Address correspondence to Dr Bauersfeld, Division of Pediatric Cardiology, University Children’s Hospital, Steinwiesstrasse 75, CH-8032, Zurich, Switzerland (Email: urs.bauersfeld{at}kispi.unizh.ch).

	Abstract

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Implantable cardioverter defibrillators in children have proven to be an effective therapy for life-threatening ventricular arrhythmias. The optimal electrode and device placement for implantable cardioverter defibrillator therapy in children is still controversial. We describe our initial experience after epicardial and pleural electrode insertion with abdominal or intrathoracic device placement in 8 children.

	Introduction

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Implantable cardioverter defibrillators (ICD) are increasingly implanted in children for primary or secondary prevention of sudden death due to life-threatening ventricular arrhythmias [1, 2]. Various ICD system implant techniques have been described for children and adults with congenital heart disease [3, 4]. Limited vascular access, patient size, and growing have led to alternative implant techniques using subcutaneous or epicardial defibrillation electrodes. With these approaches, either shock delivery has not been reliable or defibrillation thresholds have been unfavorably high. Moreover, the main risks in children are physical activity, growth-related distortion, and unfavorable position in terms of exposure to physical impact. They have resulted in a substantial number of lead fractures or dislodgement of electrodes [5], leading to inappropriate shocks [6]. Importantly, an electrical field around the heart has to be created for shock delivery and successful defibrillation. Generally this is achieved with a defibrillation electrode and an ICD device serving as the other electrode.

We describe a novel ICD system implantation technique with subpleural defibrillation coil electrodes, epicardial leads for pacing and sensing, and abdominal or intrathoracic device placement.

	Technique

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Hospital ethical committee approval and informed consent were obtained before data collection and analysis. The ICD systems were implanted in 8 children at a median age of 11.6 years (range, 2.9–13.2), and median follow up was 9.7 months (range, 1.7–23.1). Indications for ICD implantation were hypertrophic cardiomyopathy (n = 6), long QT syndrome (n = 1), and the Brugada syndrome (n = 1). Antiarrhythmic therapy with ß-blockade was prescribed and continued after ICD implantation in all patients. There were no operative complications.

In 5 patients, epicardial electrodes and the coil lead were inserted through a muscle-sparing left lateral thoracotomy in the fourth intercostal space, as described in detail by our group [7]. The parietal pleura were dissected away from the thoracic wall to create a tunnel along the third intercostal space for insertion of the defibrillation lead. A Medtronic 6937-35 or 6937-52 coil electrode (Medtronic, Minneapolis, MN) was positioned in the prepared space and secured with a stitch. Bipolar steroid-eluting epicardial leads (CapSure Epi 4968-35 [Medtronic]) were sutured to the free lateral wall of the left ventricle and to the left atrial appendage in case of dual-chamber ICD systems.

Surgical access for lead positioning was different in patients requiring concomitant cardiac repair through a median sternotomy using cardiopulmonary bypass (CPB). The parietal pleura were also undermined along the third intercostal space, the coil electrode inserted in the space, and the suture secured. Epicardial electrodes were positioned on the left atrial appendage and the left ventricle during CPB with an unloaded heart. Likewise the extrapleural coil was inserted during CPB when the lung could be totally deflated.

The leads were brought in the upper abdomen through a separate incision in the first group of patients and through the sternotomy in the second group. They were connected to various ICD devices, which were placed in the first 5 patients in the left rectus muscle sheath. In an attempt to optimize the electrical field, the device was subsequently positioned intrathoracically in the diaphragm in a horizontal position underneath the right ventricle. To achieve this, the aponeurosis of the diaphragm was dissected away from the muscle. The dissection was pursued to permit the insertion of the device, often to the level of the inferior vena cava (Figs 1A, 1B). In patients with concomitant cardiac surgery, defibrillation thresholds of 20 Joules were accepted, and no further testing was undertaken at lower energy settings. Adequate defibrillation thresholds were obtained in 6 patients, even when testing was done immediately after CPB. A second epicardial coil electrode was used in a patient with hypertrophic obstructive cardiomyopathy to achieve a defibrillation threshold of 20 Joules. Testing in this patient was potentially hazardous immediately after surgery with CPB for resection of subaortic stenosis. Ventricular fibrillation was not inducible in 2 patients with hypertrophic cardiomyopathy.

View larger version (68K): [in this window] [in a new window]   Fig 1. (A) Frontal and (B) lateral chest roentgenograms of a 6-year-old boy with subpleural placement of the defibrillator electrode and intrathoracic horizontal position of the device.

During our observation period, three appropriate and successful ICD discharges were seen in 1 patient. One inappropriate shock was documented due to sinus tachycardia. One complication with dislodgement of a defibrillation electrode was detected 12 months after implantation on routine chest roentgenogram in 1 patient. Lead repositioning was combined with repositioning of the device intrathoracically, as described. A device recall prompted one device replacement.

	Comment

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Despite advances in lead and ICD technology, the optimal ICD system implantation technique for children and patients with congenital heart disease with limited venous access has not been defined. The main obstacle is the positioning of the defibrillation electrode in case a transvenous route is neither possible nor desirable.

We describe an implantation technique with subpleural placement of the defibrillation electrode. The device was placed abdominally or it was placed between the pericardium and diaphragm in a horizontal position underneath the heart to optimize the electrical field. The systems showed adequate defibrillation thresholds, even when testing was performed immediately after CPB surgery. Sensing and pacing thresholds of the epicardial atrial and ventricular leads remained stable with time, as reported in another study [7]. Re-testing in 2 patients demonstrated stable defibrillation thresholds 20 Joules. Compared with previous reported implantation techniques with pericardial or subcutaneous electrodes [3, 4, 8], a subpleural position of the defibrillation electrode guarantees a safe lead position with little or no lead stress through cardiac or lung movements. An intrathoracic horizontal position of the device underneath the heart assures an optimal electrical field and limits lead tension, compared with placement in the rectus muscle sheath. Moreover, the intrathoracic lead and device position ensure a safe ICD system position in active patients in case of physical impacts.

A main limitation includes the short follow-up period, revealing appropriate ICD shocks in only 1 patient, and one inappropriate shock. System revision due to one defibrillation lead dislodgement was necessary early in the learning period. So far we have had no need for device exchange with the intradiaphragmatic position, although no problems for device access would be expected.

In conclusion, the implantation of ICD systems with epicardial sensing and pacing leads, and a subpleural defibrillation electrode is feasible and safe. An intrathoracic position of the device optimizes the electrical field and results in a safe and protected device position. Further follow-up is required.

	References

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1. Stefanelli CB, Bradly DJ, Leroy S, Dick II M, Serwer GA, Fischbach PS. Implantable cardioverter defibrillator therapy for life-threatening arrhythmias in young patients J Interv Cardiol 2002;6:235-244.
2. Silka MJ, Kron J, Dunnigan A, Dick II M, Pediatric Electrophysiology Society Sudden cardiac death and the use of implantable cardioverter defibrillators in pediatric patients Circulation 1993;87:800-807.[Abstract/Free Full Text]
3. Gradaus R, Hammel D, Kotthoff S, Bocker D. Nonthoracotomy implantable cardioverter defibrillator placement in children: use of subcutaneous array leads and abdominally placed implantable cardioverter defibrillators in children J Cardiovasc Electrophysiol 2001;12:356-360.[Medline]
4. Stephenson EA, Batra AS, Knilans TK, et al. A mulicenter expirience with novel implantable cardioverter defibrillator configurations in the pediatric and congenital heart disease population J Cardiovasc Electrophysiol 2006;17:41-46.[Medline]
5. Korte T, Köditz H, Niehaus M, Paul T, Tebbenjohanns J. High incidence of appropriate and inappropriate ICD therapies in children and adolescents with implantable cardioverter defibrillator Pacing Clin Electrophysiol 2004;27:924-932.[Medline]
6. Alexander ME, Cecchin F, Walsh EP, Triedman JK, Bevilacqua LM, Berul CI. Implications of implantable cardioverter defibrillator therapy in congenital heart disease and pediatrics J Cardiovasc Electrophysiol 2004;15:72-76.[Medline]
7. Dodge-Khatami A, Kadner A, Dave H, Rahn M, Prêtre R, Bauersfeld U. Left heart atrial and ventricular epicardial pacing through a left lateral thoracotomy in children: a safe approach with excellent functional and cosmetic results Eur J Cardiothorac Surg 2005;28:541-545.[Abstract/Free Full Text]
8. Cannon BC, Friedmann RA, Fenrich RA, Fraser CD, McKenzie ED, Kertesz NJ. Innovative technique for placement of implantable cardioverter-defibrillator leads in patients with limited venous access to the heart Pacing Clin Electrophysiol 2006;29:181-187.[Medline]

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This Article Abstract Full Text (PDF) 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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ali Dodge-Khatami René Prêtre Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bauersfeld, U. Articles by Prêtre, R. Search for Related Content PubMed PubMed Citation Articles by Bauersfeld, U. Articles by Prêtre, R. Related Collections Electrophysiology - arrhythmias