Ann Thorac Surg 2008;86:1701-1703. doi:10.1016/j.athoracsur.2008.04.076
© 2008 The Society of Thoracic Surgeons
How To Do It
Alternative Technique for Implanting an Implantable Cardioverter Defibrillator in Infants
Shoji Suzuki, MD, PhDa,*,
Hiroshi Watanabe, MD, PhDb,
Shinpei Yoshii, MD, PhDc,
Shigeaki Kaga, MD, PhDa,
Yoshihiro Honda, MDa,
Natsuya Ishikawa, MDa,
Masahiko Matsumoto, MD, PhDa
a Department of Surgery, University of Yamanashi, Yamanashi, Japan
b Department of Surgery, Postgraduate School of Niigata University, Niigata, Japan
c Department of Cardiovascular Surgery, Tachikawa Medical Center, Niigata, Japan
Accepted for publication April 23, 2008.
* Address correspondence to Dr Suzuki, Department of Surgery, University of Yamanashi, Shimokato, Chuo-city, Yamanashi, 409-3898, Japan (Email: ssuzuki{at}yamanashi.ac.jp).
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Abstract
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We applied a new implanting technique for an implantable cardioverter defibrillator (ICD) in a 4-month-old girl with repeated ventricular fibrillation (Vf) due to long QT syndrome. This technique consisted of placement of an oval patch lead on the outer surface of the pericardium in the left pleural cavity. This was useful in preventing the complications of the conventional epicardial patch leads (ie, crinkling of the lead and constrictive pericarditis). This patch should be contemplated as an alternative option for implanting ICD in infants.
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Introduction
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A recent study on long QT syndrome has revealed its relevance to sudden infant death syndrome, which may increase the number of potential candidates for implantable cardioverter defibrillator (ICD) implantation in infancy. However, the standard technique for implanting an ICD in infancy has not been established, mainly because the ICD system is still causing space constraints and resulting in higher rate of postoperative complications. We describe a new ICD implantation technique that may be superior to prevent the burdensome complications.
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Technique
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The patient was a 4-month-old girl, weighing 5.8 kg, diagnosed as long QT syndrome (QTc 450 
520 ms). She had an episode of aborted sudden cardiac death due to paroxysmal ventricular fibrillation at 2 months of age. She was successfully resuscitated at the local hospital, and she was referred to our hospital for further investigation. After admission, ventricular fibrillation developed in her 3 times during several weeks. The Holter electrocardiogram clearly revealed the sudden onset of the fibrillation. As she did not respond to a medical management with β-blockers and anti-arrhythmics, she was recommended an urgent ICD implantation as per the Japan Circulation Society Guidelines.
A full median sternotomy with slight caudal extension was done; the left thorax was widely opened. A unipolar epicardial oval patch lead for cardioversion and defibrillation (67215; Medtronic Inc, Minneapolis, MN) was placed on the left outer surface of the pericardium with special care not to compress the left pulmonary veins. The anterior part of the patch was fixed on the pericardium, whereas the remaining part was left unfixed, sitting naturally between the left lung and the pericardium. Then the pericardium was opened longitudinally, and a steroid eluting bipolar epicardial lead (CapSure Epi 4968 [Medtronic Inc]) was placed on the inferior surface of the right ventricle for sensing and pacing. Although atrial overdrive pacing might be useful, it was not possible due to space constraints. After the electronic status was evaluated, the pericardium was partly closed. A large pocket for a single-chamber ICD generator (GEM II VR 7229 [Medtronic Inc]) was created. The right half of the rectus abdominis was dissected and separated from the posterior lamina of the sheath, and then the pocket was enlarged rightwards between the internal abdominal oblique and the transversus abdominis muscles. The active can generator and the oval patch were placed on the opposite side of the heart so that the electric current of defibrillation would flow between them. The superior edge of the generator was positioned behind the rib cartilage to prevent friction and in turn pain. The sternum was temporarily closed and the burst test was repeated thrice at 20 Joules with an interval of 5 minutes in between. The initial defibrillation output was set at 30 Joules, the maximum output of the implanted system. The burst test before discharge was satisfactory at 10 Joules. Therefore, the output setting was decreased to 20 Joules, although the actual defibrillation threshold was not measured.
Mid-Term Results
During the 5 year, 9-month follow-up, the patient was on β-blockers and anti-arrhythmics and she had an episode of appropriate defibrillation just after the implantation (Fig 1). An inappropriate shock due to sensing failure developed in her 2 years and 7 months later; subsequently she underwent replacement of the sensing leads. The generator was replaced with a new model (Marquis VR, 7230 [Medtronic Inc]) due to a flat battery at 4 years and 7 months after the initial implantation.
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Fig 1. Successful defibrillation had been accomplished by a 29.0 Joules current revealed at early follow-up.
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As she grew well from 58 to 105 cm in height, and gained in weight from 5.8 to 15.9 kg, the oval patch lead got displaced postero-inferiorly (Fig 2). However, the system is working properly with a low defibrillation impedance of 57 ohms. Although the ICD was placed adjacent to the phrenic nerve, there was no injury to it; rather there was no diaphragm elevation. Neither pulmonary venous obstruction nor constrictive pericarditis was encountered.
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Fig 2. Chest roentgenograms show the position and the relationship of the leads and the generator. The oval patch was gradually displaced postero-inferiorly. No crinkling of the patch was seen. Shown (A) just after implantation and (B) 4 years, 7 months after implantation. (Frontal view, left side; lateral view, right side.)
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Comment
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Sudden death is a potential consequence in infants with long QT syndrome. Although parental use of an automated external defibrillator is an option, ICD is the most reliable preventer of arrhythmic death [1]. Stellate ganglionectomy might be an option, but not in situations of emergency like this one.
In terms of the technical aspect of ICD implantation in infancy, not many articles have been published. Two different techniques with some modifications have been our choice. In the first method, the electric current for defibrillation could be accomplished between a single epicardial patch lead and an active can [2]. The outcome of this was suboptimal as the patients occasionally developed crinkling of the oval patch [3] or constrictive pericarditis [4], although the epicardial system might have the advantage of keeping the defibrillation threshold relatively lower [5]. The second technique uses subcutaneous leads in subscapular position [1, 5–8]. It certainly seems to be superior, as it does not need thoracotomy. However, elevated defibrillation threshold, migration, and breakage of the leads are of concern [5, 8], because some of the subcutaneously implanted leads were originally designed for the transvenous approach.
Ours is a modified technique based on the previous epicardial patch technique. The mid-term result is seemingly encouraging in terms of preventing the previously described complications. Although the ICD implantation technique should be individualized in each infant, we conclude this method can be an alternative option to contemplate.
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References
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- Arend DJ, Harkel T, Witsenburg M, et al. Efficacy of an implantable cardioverter-defibrillator in a neonate with LQT3 associated arrhythmias Europace 2005;7:77-84.[Abstract/Free Full Text]
- Watanabe H, Hayashi J, Haga M, Saito M, Suzuki H, Sato S. Successful implantation of a cardioverter defibrillator in an infant Ann Thorac Surg 2001;72:2125-2127.[Abstract/Free Full Text]
- Molina JE, Benditt DG, Adler S. Crinkling of epicardial defibrillator patches. A common and serious problem. J Thorac Cardiovasc Surg 1995;110:258-264.[Abstract/Free Full Text]
- Barrington WW, Deligonul U, Easley AR, Windle JR. Defibrillator patch electrode constriction: an underrecognized entity Ann Thorac Surg 1995;60:1112-1116.[Abstract/Free Full Text]
- Stephenson EA, Batra AS, Knilans TK, et al. A multicenter experience with novel implantable cardioverter defibrillator configurations in the pediatric and congenital heart disease population J Cardiovasc Electrophysiol 2006;17:41-46.[Medline]
- Thogersen AM, Helvind M, Jensen T, Andersen H, Jacobsen JR, Chen X. Implantable cardioverter defibrillator in a 4-month-old infant with cardiac arrest associated with a vascular heart tumor Pace 2001;24:1699-1700.[Medline]
- Greene AE, Moak JP, Di Russo G, Berger JT, Heshmat Y, Kuehl KS. Transcutaneous implantation of an internal cardioverter defibrillator in a small infant with recurrent myocardial ischemia and cardiac arrest simulating sudden infant death syndrome Pace 2004;27:112-116.[Medline]
- Kriebel T, Ruschewski W, Gonzalez MGY, et al. ICD implantation in infants and small children: The extracardiac technique Pace 2006;29:1319-1325.[Medline]
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Abstract
Introduction
