Epicardial Implantable Cardioverter Defibrillator Research Articles

Utility of routine follow-up defibrillation safety margin testing in young patients with epicardial implantable cardioverter-defibrillators.

Routine defibrillation threshold testing (DFT) of transvenous implantable defibrillators (ICDs) has largely been in decline. In patients with non-transvenous ICDs that utilize subcutaneous and pleural ICD leads, serial DFT testing can detect a significant number of failures. Data about the utility of follow-up defibrillation safety margin testing (DSM) testing in pediatric patients and young adults with an epicardial ICD are lacking. Patients aged<25 years old who underwent epicardial ICD placement at Mayo Clinic from 2014 to 2023 with at least one follow-up DSM test were included. The patients were divided into a "routine" (R) and "clinically indicated" (CI) group based on the index of clinical concern. Inadequate DSM was defined as unsuccessful defibrillation at an output of less than 10 J below the maximum output of the device. The purpose of this study was to assess the utility of follow-up DSM testing. An epicardial ICD system was placed in 122 patients. A total of 26 patients met inclusion criteria and underwent a total of 47 DSM follow up tests. Inadequate DSM occurred in 1/33 (3%) in the R group and 2/14 (14%) DSM tests in the CI group. The median follow-up period was 54 and 36 months for the R and CI group, respectively. Our data suggest that epicardial ICDs are reliable and routine follow-up DSM testing may not be necessary for all patients. DSM testing should be performed in individuals with epicardial ICD systems when there is clinical concern about lead or coil performance.

Epicardial vs. transvenous implantable cardioverter defibrillators in children.

The implantable cardioverter defibrillator (ICD) has been increasingly used in children. Both epicardial and transvenous approaches are used, with controversy regarding the best option with no specific recommendations. We aimed to compare outcomes associated with epicardial vs. transvenous ICDs in children. Data were analysed from a retrospective study including all patients <18-year-old implanted with an ICD in a tertiary centre from 2003 to 2021. Outcomes were compared between epicardial and transvenous ICDs. A total of 122 children with an ICD (mean age 11.5 ± 3.8 years, 57.4% males) were enrolled, with 84 (64.1%) epicardial ICDs and 38 (29.0%) transvenous ICDs. Early (<30 days) ICD-related complications were reported in 17 (20.2%) patients with an epicardial ICD vs. 0 (0.0%) with a transvenous ICD (P = 0.002). Over a mean follow-up of 4.8 ± 4.0 years, 25 (29.8%) patients with an epicardial ICD and 9 (23.7%) patients with a transvenous ICD experienced at least one late ICD-related complication [hazard ratio (HR) 1.8, 95% confidence interval (CI) 0.8-4.0]. Implantable cardioverter defibrillator lead dysfunction occurred in 19 (22.6%) patients with an epicardial ICD vs. 3 (7.9%) with a transvenous ICD (HR 5.7, 95% CI 1.3-24.5) and was associated with a higher incidence of ICD-related reintervention (HR 3.0, 95% CI 1.3-7.0). After considering potential confounders, especially age and weight at implantation, this association was no longer significant (P = 0.112). The freedom from ICD lead dysfunction was greater in patients with pleural coils than in those with epicardial coils (HR 0.38, 95% CI 0.15-0.96). In children, after a consideration of patient characteristics at implantation, the burden of complications and ICD lead dysfunction appears to be similar in patients with epicardial and transvenous devices. Pleural coils seem to be associated with better outcomes than epicardial coils in this population. NCT05349162.

Abstract 15143: Painless Epicardial Implantable Cardioverter Defibrillator Net System With Electric Conductive Fibers

Introduction: Current Implantable cardioverter-defibrillator (ICD) needs high CD shock (35J), which is not tolerable under consciousness. Our multi-physics computer-simulation demonstrated extra-low energy defibrillation (0.36J)can be possible if sheet electrodes are arranged upper (base) and lower (apex) side of the heart. Hypothesis: We developed the epicardial ICD net electrodes system (Ep-ICD) made of upper and lower parts with fine conductive fibers. The objective of this study was to test whether Ep-ICD can stop ventricular fibrillation with painless level (&lt;0.7J) in large animal model. Methods: Ep-ICD was constructed by fine tungsten fibers using computer-assisted knitting machine (Shimaseiki Co., Japan). Middle part was knitted by polyester fibers. Upper and lower electrode nets were connected to RV and SVC coils of DF-1 lead (Medtronic), respectively. Five beagle dogs were used for this experiment. The Ep-ICD net was directly attached to the heart, and electrodes were connected to commercially available ICD system. DC discharges were controlled by telemetry controller. Vf was induced by attaching 9V battery onto the heart surface. Ten seconds after Vf induction, DC was delievered from minimal energy 0.4J (Medtronic Viva XT) or 0.1J (Boston Scientific Perciva). DC energy was gradually increased until defibrillation was accomplished. After 3 minutes of recovery, the ventricular fibrillation induction and defibrillation tests were repeated. Defibrillation threshold (DFT) was defined as 75% of success of defibrillation. To compare current ICD system, commercial ICD lead was inserted in one dog through internal juglar vein, and defibrillation test was conducted. Results: Defibrillation was accomplished by 0.1J~1J, All hearts recovered instantaneously to sinus rhythm. DFT were 0.6J for 4 dogs and 0.8J for one dog. Current ICD system needed 30J for defibrillation. Conclusions: Our preliminary results shows that the Ep-ICD accomplished defibrillation with painless level of DC energy (&lt;0.7J). Extra-low energy DC can avoid electroporation which causes conduction abnormality or malignant arrhythmia. Ep-ICD can apply DC shock before losing consciousness, which has a huge merit for QOL.

Left Mini Thoracotomy as a Method for Epicardial Implantable Cardioverter-Defibrillator Placement in a Child. An Effective Alternative to the Transvenous Approach

In infants and children, the small size of the systemic veins precludes safe and durable transvenous placement of automatic internal cardiac defibrillator (ICD). In such cases, an alternative method of implanting an automatic ICD is via thoracotomy. This report describes the technique used at Onassis Cardiac Surgery Center for the epicardial placement of an ICD system with a transvenous ICD coil placed in the posterior pericardium via a left thoracotomy, producing a stable location and excellent coil-to-can vector for successful defibrillation. To the best of our knowledge, this is the first case in Greece.

Long-term outcome of epicardial implantable cardioverter-defibrillator systems in children: results justify its preference in paediatric patients.

The question of whether transvenous or epicardial implantable cardioverter defibrillator (ICD) system is more beneficial in children and adolescents is controversially discussed. We sought to analyse the long-term outcome after implantation of ICDs using epicardial pacing/sensing and pleural shock leads. Retrospective analysis of 31 consecutive patients undergoing a total of 55 implantations of epicardial/pleural ICD systems below 20 years of age. Median age at implantation was 11.4 years (range 2.2-20) and median follow-up 57 months (range 0.4-127). The ICDs were implanted for primary (n = 17) and for secondary prevention (n = 14). The first defibrillation threshold at implantation was ≤25 J in 94% of the implant procedures. Appropriate shocks occurred in 6 of 31 patients. Inappropriate shocks occurred in 4 of 31 patients triggered by lead fracture, T-wave oversensing, sinus tachycardia, and atrial fibrillation. Freedom from first ICD discharge was 81, 71, and 71% at 3, 6, and 9 years, respectively. Reoperation was indicated in 16 of 31 patients for lead failure (n=11), end of battery life (n=10), generator migration (n=1) and recall (n=1); freedom from reoperation was 74 and 55% at 3 and 6 years. Paediatric epicardial/pleural ICD therapy is feasible, effective, and safe both in the short-term as well as in the long-term perspective at the price of relatively frequent surgical revisions. They do not generally result in an increased burden of inappropriate shocks. This ICD system meets the needs of the paediatric population and can be recommended as a first choice in this age group.

Minimally invasive epicardial implantable cardioverter-defibrillator placement for infants and children: An effective alternative to the transvenous approach

Young patients have high rates of implantable cardioverter-defibrillator (ICD) lead fractures and are at risk for venous occlusion or tricuspid regurgitation with transvenous lead placement. Epicardial ICDs have the potential to circumvent complications associated with transvenous ICDs, but the literature on young patients remains limited. The purpose of this study was to evaluate the results of a minimally invasive epicardial ICD lead placement approach in young patients. A retrospective, institutional review board-approved electronic medical record review of all patients undergoing epicardial ICD placement at our institution from January 2011 to December 2015 was performed. A total of 46 patients (20 female [43%]; mean age 10.3 years, range 0.7-18.2 years; mean weight 41 ± 21 kg) were identified; 24 (52%) were ≤10 years old. A minithoracotomy was used in 28 patients (61%). All had acceptable defibrillation, right ventricular sensing, and stimulation thresholds. Median follow-up was 2.0 ± 1.3 years (range 0.02-4.5 years). Eight surgical complications occurred in 7 patients (15%), and 8 device-related complications occurred in 6 patients (13%). Fifty-eight appropriate shocks were delivered in 7 patients (15%). Four patients received inappropriate shocks in relation to lead fractures/microfractures. One patient in this cohort who had long QT syndrome type 8 died of a hypoglycemic seizure. Minimally invasive epicardial ICD placement provides an effective, alternative method for implanting an ICD system, particularly in very young patients (<6 years of age) or patients who are concerned about cosmetic appearance. This technique is an acceptable alternative to traditional transvenous ICD placement.

Minimally invasive percutaneous pericardial ICD placement in an infant piglet model: Head-to-head comparison with an open surgical thoracotomy approach

Epicardial implantable cardioverter-defibrillator (ICD) placement in infants, children, and patients with complex cardiac anatomy requires an open surgical thoracotomy and is associated with increased pain, longer length of stay, and higher cost. The purpose of this study was to compare an open surgical epicardial placement approach with percutaneous pericardial placement of an ICD lead system in an infant piglet model. Animals underwent either epicardial placement by direct suture fixation through a left thoracotomy or minimally invasive pericardial placement with thoracoscopic visualization. Initial lead testing and defibrillation threshold testing (DFT) were performed. After the 2-week survival period, repeat lead testing and DFT were performed before euthanasia. Minimally invasive placement was performed in 8 piglets and open surgical placement in 7 piglets without procedural morbidity or mortality. The mean initial DFT value was 10.5 J (range 3-28 J) in the minimally invasive group and 10.0 J (range 5-35 J) in the open surgical group (P = .90). After the survival period, the mean DFT value was 12.0 J (range 3-20 J) in the minimally invasive group and 12.3 J (range 3-35 J) in the open surgical group (P = .95). All lead and shock impedances, R-wave amplitudes, and ventricular pacing thresholds remained stable throughout the survival period. Compared with open surgical epicardial ICD lead placement, minimally invasive pericardial placement demonstrates an equivalent ability to effectively defibrillate the heart and has demonstrated similar lead stability. With continued technical development and operator experience, the minimally invasive method may provide a viable alternative to epicardial ICD lead placement in infants, children, and adults at risk of sudden cardiac death.

Implantation of looped epicardial cardioverter defibrillator coil on the surface of the right ventricular outflow tract.

We present the early results of looped epicardial cardioverter defibrillator coil implantation on the anterior surface of right ventricular outflow tract in infants and children. Patients with a surgical history of an epicardial implantable cardioverter defibrillator system between 2013 and 2014 were included in the study. Patient age, gender, body weight, indications for a cardioverter defibrillator system implantation, defibrillation threshold values, and defibrillation therapies were retrospectively evaluated. There were eight patients with a mean age of 4.4 ± 2.9 years and a mean body weight of 19.5 ± 11.7 kg. Five of the patients had been diagnosed with long QT syndrome, one patient had been diagnosed with genetic channelopathy and noncompaction of the left ventricle, and two patients had been diagnosed with univentricle physiology. The implantable cardioverter defibrillator system was composed of pace-sense leads, an abdominal active can, and a defibrillation coil placed below the pulmonary valve annulus on the anterior surface of the heart. The mean defibrillation threshold was 6.6 ± 2.3 joules. There were four appropriate therapies in two patients in a mean follow-up of 9 ± 6.5 months. The significantly low defibrillation thresholds with the defibrillation coils located below the pulmonary valve annulus are encouraging. However, a larger patient series will be necessary to evaluate the safety and reliability of this technique.

Surgical techniques for implanting implantable cardioverter defibrillators in children and infants

Implantable cardioverter defibrillators (ICDs) are now being used in children. ICDs can be used to prevent sudden cardiac death caused by not only congenital heart defects, but also various non-structural diseases, such as long QT syndrome. However, a standard implantation technique for children, especially infants, has not yet been established. As the surgical implantation in infants is not amenable to transvenous lead placement, it was necessary to choose from epicardial, subcutaneous and pericardial ICD systems. However, many of these systems are associated with high rates of late complications. Lead fracture, insulation breakage, migration, buckling or crinkling of the patch lead and constrictive pericarditis have been reported as the most common lead-related complications. An increase in the defibrillation threshold is another issue that must be considered when using an ICD in a child or infant. Further studies on the outcomes, psychosomatic impact and other specific complications in the pediatric population need to be considered. The clinical use of ICDs in infants is still limited. Therefore, it is important to have many surgical options available so that the treatment can be custom-tailored to suit individual patients.

Subxiphoid Approach to Epicardial Implantation of Implantable Cardioverter Defibrillators in Children

Epicardial implantation of implantable cardioverter defibrillators (ICDs) is considered in the presence of intracardiac shunt, venous access issue, or small body size. We report our experience with epicardial ICD coil implantation using a minimally invasive method. Nine patients who underwent epicardial ICD implantation were included. The median age was 7.4 years (3.9-9.6 years) and the median weight was 15 kg (12-24 kg). Diagnosis at the time of implantation included long QT syndrome (n = 5), catecholaminergic polymorphic ventricular tachycardia (n = 2), hypertrophic cardiomyopathy (n = 1), and fast monomorphic ventricular tachycardia (n = 1). The minimally invasive method involved a subxiphoid incision to place the epicardial pacing leads. The ICD coil was placed in the transverse sinus in four patients using an access path posterior to the heart. The second approach involved a path anterior to the heart to reach the epicardial location posterior to the left atrial appendage in the five remaining patients. No fluoroscopy was used in either approach. The median defibrillation threshold (DFT) at implantation was 7.5 J. Lower DFTs were observed in the anterior approach (10 J vs 5 J). Appropriate ICD shocks were observed in three patients during the median 18-month follow-up period (0.3-28 months). No inappropriate shocks were noted. One patient developed pericardial tamponade 39 days after the procedure and was surgically drained. Minimally invasive epicardial ICD coil implantation in children with low DFT values is possible. The anterior implantation approach appears superior to the posterior approach.

Percutaneous, Ultrasound-Guided Stellate Ganglion Nerve Block Suppresses Recurrent Ventricular Fibrillation in an Infant Awaiting Heart Transplant

Percutaneous stellate ganglion nerve block has been used to treat chronic pain syndromes. It has been described for refractory ventricular arrhythmias.1,2 However, it has rarely been described in an infant.3,4 To the best of our knowledge, this block has not been used at this age as a diagnostic challenge and therapeutic bridge to surgical left cardiac sympathetic denervation (LCSD) and cardiac transplant. This patient presented shortly after birth with orthodromic reciprocating tachycardia and ventricular preexcitation. She was treated with propranolol and discharged. Three months later, she became rigid and cyanotic at home, requiring cardiopulmonary resuscitation, cardioversion, and amiodarone for ventricular tachycardia (VT). She underwent electrophysiology study with successful ablation of her accessory connection, but in the following days she developed recurrent ventricular fibrillation. Magnetic resonance imaging revealed asymmetric left ventricular hypertrophy, otherwise normal anatomy and no focal lesions; catheterization was nondiagnostic. An epicardial implantable cardioverter-defibrillator (ICD) was placed 13 days after presentation, and she was discharged home on amiodarone and propranolol. At 7 months of age, she had 28 appropriate shocks for monomorphic VT, polymorphic VT, and ventricular fibrillation over 3 days, …

Jak należy postąpić z bezobjawową skrzepliną na elektrodzie defibrylującej?

A 35-year-old woman received an implantable cardioverterdefibrillator (ICD) for primary prevention of sudden cardiac death. One day after implantation, transesophageal echocardio graphy (TEE), carried out before defibrillation threshold testing, revealed a large, mobile, grape-shaped mass attached to the defibrillator lead in the right atrium (RA), fortunately with no symptoms. Anticoagulant therapy was started immediately. Serial TEE demonstrated that, although still asymptomatic, the RA mass was enlarged. Accordingly, thrombectomy, lead extraction and placement of an epicardial ICD lead were performed. Correct pacing and defibrillation thresholds were obtained. The patient was discharged 4 days later and during 1 month follow-up remained in good condition with no recur

Nontraditional Implantable Cardioverter Defibrillator Placement in Adult Patients with Limited Venous Access: A Case Series

Conventional transvenous approaches for implantable cardioverter defibrillator (ICD) lead placement are not possible in some patients with limited venous access or severe tricuspid valve dysfunction. We retrospectively identified six patients who underwent ICD placement or revision requiring nontraditional alternative surgical lead placement at our institution between November 2006 and August 2008. The baseline and operative patient characteristic data were accumulated and reviewed. All the patients (mean age 71 +/- 3.4 years) underwent nontraditional surgical placement of epicardial ICD leads and traditional placement of ventricular epicardial bipolar pacing/sensing leads. Five patients had the distal lead tip fixed to the anterior epicardium of the right ventricular outflow tract, which was then looped under and around the ventricles, forming a "sling," and tunneled to a left subclavicular pocket. One patient had a single unipolar subcutaneous array lead fashioned into a "loop" and placed under the inferior aspect of the ventricles. The average procedure time was 311 +/- 115 minutes with a mean defibrillatory threshold (DFT) of < or = 22 + 3 J. Post-procedure hospitalization was 9.3 +/- 4.4 days and no device-related complications were encountered. Mean device follow-up of 451 + 330 days showed normal function and two appropriate successful ICD discharges. Nontraditional alternative surgical methods for the placement of ICD systems in adult patients with limited venous access or TV dysfunction can achieve results similar to those of conventionally placed endovascular leads with limited complications and comparable DFTs in short-term follow-up.

Epicardial and pleural lead ICD systems in children and adolescents maintain functionality over 5 years

The optimal implantable cardioverter defibrillator (ICD) system implant technique has not yet been defined in young patients and those with congenital heart disease (CHD). We describe our 5-year experience with epicardial pacing/sensing leads secured on the left cardiac chambers and a pleural defibrillation lead insertion along the third intercostal space. Implantable cardioverter defibrillator systems were implanted in 15 children and adolescents (age: 2.9-20.0 years) for primary (n = 11) or secondary (n = 4) prevention. Underlying CHD were hypertrophic (n = 10) or dilative cardiomyopathies (n = 2), primary electrical diseases (n = 2), and transposition of the great arteries (n = 1). Devices were placed in the rectus sheath (n = 5), or within the diaphragm (n = 10). Median defibrillation threshold at implant was 15 J (range: 10-25). During 5 years of follow-up (median: 22 months), nine appropriate and two inappropriate ICD discharges occurred. Four system revisions were required due to device recall, pleural lead dislodgement, epicardial lead fracture, and insulation break. Twelve months after the implantation, defibrillation threshold testing demonstrated stable thresholds of <or=20 J in five patients. Our 5-year experience demonstrates the efficacy of epicardial and pleural lead ICD systems. Inappropriate shocks and lead failures are observed as in other ICD systems. It represents an alternative implant technique for young and active patients and those without venous access.

Endoscopy in patients with implanted electronic devices

Endoscopy in patients with implanted electronic devices

Unipolar ventricular pacing reduces inappropriate shocks from a separate cardioverter defibrillator in a post-Fontan patient

This report describes a 20-year-old man with complex congenital heart disease and inappropriate epicardial implantable cardioverter defibrillator (ICD) shocks secondary to double counting of ventricular-paced spikes and QRS complexes from a separate bipolar epicardial dual-chamber pacemaker. Adjusting to a unipolar paced-ventricular mode resolved any double counting via pacemaker-ICD interaction.

BRONCHOMEDIASTINAL FISTULA CAUSED BY IMPLANTABLE CARDIOVERTER DEFIBRILLATOR EPICARDIAL PATCH ELECTRODE

INTRODUCTION: The implantable cardioverter defibrillator (ICD) was approved for general use in the United States in 19851. Although most current devices employ transvenously placed endocardial leads, earlier devices utilized epicardial electrodes placed by thoracotomy. We describe a case of a bronchomediastinal fistula caused by an epicardial ICD patch electrode.

Myocardial imaging in patients with defibrillator patch electrodes

Radionuclide imaging methods such as single-photon emission tomography (SPECT) and positron emission tomography (PET) are well-established techniques to evaluate myocardial ischemia and viability in patients with coronary artery disease. 1‐3 Life-threatening ventricular tachyarrhythmias are frequent findings in these patients. There is growing consensus that implantable cardioverter defibrillator (ICD) therapy reduces the incidence of sudden cardiac death in this group. 4‐8 Considering the progressive nature of the underlying disease, these patients may require radionuclide imaging to guide further therapy. Initiated by anecdotal evidence of a discrepancy between coronary angiography (no significant stenosis), thallium-201 (Tl-201) SPECT (persistent defect), and fluorodeoxyglucose-18 (F-FDG-18) PET (no defect) in patients with epicardially placed ICD leads, we investigated the hypothesis that epicardial ICD patch electrodes cause pseudodefects with SPECT. Therefore, Tl-201 SPECT, technetium-99m (Tc-99m) SPECT, and FFDG-18 PET measurements with a thorax phantom were performed to validate findings in patients and to clarify the effects of photon attenuation in the ICD patch electrode in relation to patch location, patch material composition, and the choice of nuclearcardiologic imaging modality. ICD patch electrodes placed directly on the epicardium were frequently used until recently. 9 ‐11 ••• Three different patch electrodes were examined: model 6897-M (Medtronic, Minneapolis, Minnesota), model L67 (CPI, St. Paul, Minnesota), and model 1501 (Siemens, Erlangen, Germany). The electrodes are shown in Figure 1. Technical specifications and attenuation coefficients for gamma radiation of the Medtronic and the CPI electrodes are listed in Table 1. The Siemens electrode is identical in composition to the CPI electrode.

Epicardial cardioverter-defibrillators do not cause postoperative arrhythmias

The CABG Patch Trial is a controlled, multicenter clinical trial that randomized high-risk patients undergoing coronary artery bypass grafting (CABG) to prophylactic implantation of an epicardial implantable cardioverter-defibrillator (ICD) or to no additional treatment, permitting a controlled evaluation of the effect of epicardial ICDs on the incidence of postoperative arrhythmias. We found no significant difference in the development of postoperative arrhythmias between patients who received epicardial ICDs and the control group treated with CABG alone.

Gross and microscopic pathological changes associated with nonthoracotomy implantable defibrillator leads.

Although the effects of epicardial implantable cardioverter-defibrillator (ICD) leads on underlying cardiac tissue have been reported, the gross and microscopic changes associated with endocardial ICD leads are less well described. This study describes the gross and microscopic changes associated with endocardial ICD leads in humans. The hearts from 8 patients were examined. At the time of ICD implantation, the patients' mean age was 47+/-11 years, and the left ventricular ejection fraction was 0.24+/-0.10. Four patients had ischemic heart disease, and 4 had dilated cardiomyopathy. Five hearts were examined after transplantation; 3, after death. The electrode-myocardial interfaces were characterized by intense endocardial fibrosis and were remarkably consistent. Each lead was encased by a ring of fibroelastic tissue, and there was fibrosis of the right ventricular myocardium adjacent to the leads. Fibrosis involved the tricuspid valve in 5 patients, and 1 had perforation of the valve by the lead. Microscopically, interstitial fibrosis was adjacent to each lead in the current path of ICD shocks. Acute cell injury was present only in the hearts that had received recent shocks. The ICD electrode-myocardial interface is characterized by intense fibrosis. The fibrosis associated with endocardial ICD leads and the cumulative acute damage produced by defibrillation discharges may explain changes in the defibrillation and pacing thresholds and the difficulty of lead extraction that can be encountered with transvenous ICD systems.