A novel approach to eliminate intraventricular lead placement in patients with congenital heart disease

Abstract

We describe two patients with congenital heart disease who were referred for implantable cardioverter-defibrillator (ICD) placement. Both patients possessed factors causing the conventional transvenous approach to be undesirable. We therefore devised a technique which circumvented both intravascular ICD lead placement, as well as placement of leads across the tricuspid valve. For both patients, a bipolar pace-sense lead was successfully placed in a branch of the coronary sinus. A shocking coil was then tunneled from the posterolateral margin of the device pocket, being positioned posterior and inferior to the cardiac silhouette. Defibrillation testing was carried out with goal of a 10-J safety margin. We were able to successfully achieve ICD implantation in both patients with complex congenital heart disease without requirement for surgical thoracotomy or a lead across the AV valve. R waves in excess of 5 mV were obtained and acceptable defibrillation characteristics were achieved. Both patients are doing well after mid-term follow-up. A new implant approach is presented, which involves minimal intravascular hardware and eliminates passage across the atrioventricular valve for patients with congenital heart disease in whom conventional ICD implant techniques may be undesirable or not possible. This procedure is technically straightforward with proper technique and knowledge of the patient specific anatomy.