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J Thorac Cardiovasc Surg 2007;133:1375-1376
© 2007 The American Association for Thoracic Surgery

Brief Communication

Minimally invasive implantation of a cardioverter-defibrillator in a small patient

Christopher S. Snyder, MDa,*, Victor Lucas, MDa, Thomas Young, MDa, Rani Darling, RNa, Geeta Dalal, MDa, James E. Davis, MDb

a Division of Pediatric Cardiology, the Ochsner Clinic Foundation, New Orleans, La
b Division of Cardiovascular Surgery, the Ochsner Clinic Foundation, New Orleans, La.

Received for publication December 21, 2006; accepted for publication January 2, 2007.

* Address for reprints: Christopher Snyder, MD, Ochsner Clinic Foundation, Department of Pediatric Cardiology, 1514 Jefferson Highway, New Orleans, LA 70121. (Email: csnyder{at}ochsner.org).

The patient is a 3-year-old girl weighing 13 kg, with a diagnosis of long QT syndrome, who experienced an episode of syncope and was found to be in ventricular fibrillation. She was cardioverted and transported to our institution. On arrival, she was taken to the operating room for implantation of an epicardial cardioverter-defibrillator. Because of her small size, this implantation was performed by using a previously unreported minimally invasive technique.

Clinical Summary

In the operating room general anesthesia was achieved. A midline incision was made over the xiphoid that extended 3 cm inferiorly. The linea alba was divided, and the retrosternal space was entered and developed. A 3-cm longitudinal pericardial incision was made, and a retractor was placed inside the pericardial sac to elevate the sternum.

A 58-cm dual-coil shocking lead (Medtronic 6949) was looped around the ventricles, with the distal coil coming to rest on the anterior right ventricular wall and the more proximal portion of the lead emerging from the posterior pericardial sac along the diaphragm. The distal coil was secured with an epicardial-encircling suture. The midportion of the lead was fixed to the diaphragmatic surface of the right ventricle. The lead was then looped along the right ventricular diaphragmatic surface, positioning the proximal coil from the apex to the base of the heart. Additional epicardial sutures were used to secure the coil along the inferior ventricular surface. This maneuver allowed sufficient myocardial mass to be interposed between the coils.

A 35-cm bipolar, steroid-eluting pace-sense lead (Medtronic 4968) was sutured to the anterior right ventricular wall. On testing, the lead had excellent sensing and pacing thresholds. The implantable cardioverter-defibrillator (ICD) pocket was made in the left abdominal wall. The leads were tunneled from the preperitoneal space into the pocket. The pacing portion of the defibrillation lead was capped, and the coil leads were inserted into the pulse generator (En-Trust, Medtronic). The bipolar ventricular pace-sense lead was inserted into the pacing position (Figure 1).


Figure 1
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  		Figure 1. Residual scar post ICD implant. ICD, Implantable cardioverter defibrillator.

 
At this point, the ICD was tested 2 times. Ventricular fibrillation was induced, and the device detected all beats of the tachycardia and delivering a 15-joule shock, successfully restoring sinus rhythm both times. After fascia and skin closure, the patient was extubated in the operating room (Figure 2).


Figure 2
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  		Figure 2. X-ray illustrating ICD and lead placement. ICD, Implantable cardioverter defibrillator.

 
Discussion

In recent years, the number of patients meeting the criteria for implantation of an ICD has increased dramatically. A number of creative implantation methods have been reported, but each is faced with its own set of potential complications.1-3Go These complications range from postpericardiotomy syndrome4Go to lead or patch trauma and failure.5Go

There are a number of advantages to this implantation, the first of which is that the patient avoids a median sternotomy, and the second of which is that no subcutaneous array is required, therefore eliminating the possibility of array failure.

This case is evidence that a minimally invasive approach to pediatric ICD implantation can be successful. In a patient determined to be too small for traditional transvenous implantation or with a lack of venous access, this method of ICD implantation should be considered.

References

  1. Cannon BC, Friedman RA, Fenrich AL, et al. Innovative techniques for placement of implantable cardioverter-defibrillator leads in patients with limited venous access to the heart. Pacing Clin Electrophysiol 2006;29:181-187.[Medline]
  2. Berul CI, Triedman JK, Forbess J, et al. Minimally invasive cardioverter defibrillator implantation for children: An animal model and pediatric case report. Pacing Clin Electrophysiol 2004;24:1789-1794.
  3. Luedemann M, Hund K, Stertmann W, et al. Implantable cardioverter defibrillator in a child using a single subcutaneous array lead and an abdominal active can. Pacing Clin Electrophysiol 2004;27:117-119.[Medline]
  4. Stefanelli CB, Bradley DJ, Leroy S, et al. Implantable cardioverter defibrillator therapy of life-threatening arrhythmias in young patients. J Interv Card Electrophysiol 2002;6:235-244.[Medline]
  5. Kettering K, Mewis C, Dornberger V, et al. Long-term experience with subcutaneous ICD leads: a comparison among three different types of subcutaneous leads. Pacing Clin Electrophysiol 2004;27:1355-1361.[Medline]



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