Implantable cardioverter-defibrillators (ICDs) have revolutionized the treatment of acquired or inherited cardiac diseases associated with a high risk of sudden cardiac death due to ventricular tachyarrhythmias. Contemporary ICD devices offer reliable arrhythmia detection and discrimination algorithms and deliver highly efficient tachytherapies. Percutaneously inserted transvenous defibrillator coils with pectoral generator placement are the first-line approach in the majority of adults due to their extensively documented clinical benefit and efficiency with comparably low periprocedural implantation risks as well as the option of providing pain-free tachycardia treatment via anti-tachycardia pacing (ATP), concomitant bradycardiaprotection, and incorporation in a cardiac resynchronization therapy if indicated. Yet, expanding ICD indications particularly among younger and more complex patient groups as well as the increasingly evident long-term consequences and complications associated with intravascular lead placements promoted the development of alternative ICD configurations. Most established in daily clinical practice is the subcutaneous ICD but other innovative extravascular approaches like epicardial, pericardial, extra-pleural, and most recently substernal defibrillator coil placements have been introduced as well to overcome shortcomings associated with traditional devices and allow for individualized treatment strategies tailored to the patients characteristics and needs. The review aims to provide practical solutions for common complications encountered with transvenous ICD systems including restricted venous access, high defibrillation/fibrillation thresholds (DFTs), and recurrent device infections. We summarize the contemporary options for non-traditional extravascular ICD configurations outlining indications, advantages, and disadvantages.
The high prevalence of atrial fibrillation (AF) in the overall population and its association with substantial morbidity, increased mortality and health care cost has instigated significant basic and clinical research efforts over recent years. The publication of multiple new high-quality randomized multi-center trials in the area of AF management and the rapidly evolving technological progress in terms of diagnostic possibilities and catheter ablation in recent years demanded a revision of the previous ESC AF Guidelines from 2016. The 2020 guidelines provide up-to-date, evidence-based guidance for the management of AF. One of the most important innovations is the presentation of a new concept for structural characterization of AF (the “4S AF scheme”) replacing the traditional classification based on its temporal pattern alone (paroxysmal-persistent-permanent). The 4S-AF-scheme highlights the importance of systematic assessment of stroke risk, severity of symptoms, total AF burden and underlying substrate as the foundation for effective and individualized AF treatment for each and every patient. Further novelties relate to the presentation of an easy and intuitive management pathway (“ABC pathway”) and strengthening the recommendations for early rhythm control, in particular the role of first line catheter ablation in heart failure. Another core component of the guidelines is the focus on patient involvement to achieve optimal outcomes. Patient education, shared decision making and incorporation of patient values and patient reported outcome of treatment interventions as well as integrated care by a multidisciplinary team all have a central role in the proposed management pathway for AF.
Background Epicardial ICD systems and CRT‐Ds using high voltage coils represent an alternative to transvenous systems in patients without central venous access and prior device complications including infection. Objective We present a case series in the adult population of epicardial ICD/CRTD systems using high voltage epicardial coils. We summarize the existing data regarding techniques, efficacy, and safety. Methods A retrospective board approved medical record review was conducted for all patients undergoing epicardial ICD/CRTD placement at our institution between January 2010 and May 2020. The literature was reviewed for prior published trials, case reports, and case series of epicardial high voltage coil insertions. Results Eleven patients (six female, mean age 48 years) underwent epicardial ICD/CRTD implant including 5/11 completely epicardial CRTD systems. The procedure was performed via median sternotomy in eight patients, left anterior thoracotomy in two patients, and sub‐xiphoid approach in one patient. After a mean follow up of 35 months, appropriate successful shocks were delivered in two (18%) patients and no patients received an inappropriate shock. Three of five (60%) patients had volumetric remodeling with CRT with significant improvement of LV EF. Device‐related complications requiring a surgical/percutaneous revision or another DFT test occurred in six patients (54%). One patient died during follow up due to refractory heart failure. No cases of epicardial device infection, coronary artery compression, constrictive pericarditis, or erosion of defibrillator coils into intrathoracic organs were reported. No randomized studies comparing safety and efficacy of traditional transvenous or subcutaneous ICD systems and epicardial ICD systems using contemporary high voltage coils were found nor any studies directly comparing epicardial defibrillator patches versus epicardial coils. Thirteen case series and 24 single case reports published between 2004 and 2020 were identified describing in total a heterogenous group of 188 patients with ICD systems incorporating one or more epi‐ or pericardially positioned shock coils. Conclusion The use of epicardial defibrillation coils for ICD/CRT‐D is a feasible treatment option for patients with either failed or contraindicated transvenous ICD systems. Dedicated epicardial high voltage leads with integrated pace‐sense electrodes and specialized delivery tools for minimal invasive implantations may improve longer term outcomes.
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