Implantable cardioverter defibrillator therapy in paediatric practice: a single-centre UK experience with focus on subcutaneous defibrillation

Abstract

AimsSudden cardiac death (SCD) risk can be managed by implantable cardioverter defibrillators (ICD). Defibrillation shocks can be delivered via ICD generator and/or intracardiac or subcutaneous coil configurations. We present our single-centre use of childhood ICDs. Methods and resultsTwenty-three patients had ICD implantation, with median age and weight of 12.96 years and 41.35 kg. Indications included eight long QT; four hypertrophic cardiomyopathy; three Brugada syndrome; two idiopathic ventricular fibrillation; two post-congenital heart repair; two family history of SCD with abnormal repolarization; one catecholaminergic polymorphic ventricular tachycardia; and one left ventricle non-compaction. Twelve had out of hospital cardiac arrests prior to implantation. Techniques included 13 conventional ICD implants (pre-pectoral device with endocardial leads), 7 with subcutaneous defibrillation coils (sensing via epicardial or endocardial leads tunnelled to the ICD), and 3 with exclusive subcutaneous ICD (sensing and defibrillation via the same subcutaneous lead). Satisfactory defibrillation efficacy and ventricular arrhythmia sensing was confirmed at implantation. Follow-up ranged from 0.17 to 11.08 years. One child died with the ICD in situ. Ten children received appropriate shocks; five on more than one occasion. Five received inappropriate shocks (for inappropriate recognition of sinus tachycardia or supraventricular tachycardia). Five children underwent six further interventions; all had intracardiac leads. ConclusionInnovative shock delivery systems can be used in children requiring an ICD. The insertion technique and device used need to accommodate the age and weight of the child, and concomitant need for pacing therapy. We have demonstrated effective defibrillation with shocks delivered via configurations employing subcutaneous coils in children.--

Right-sided subcutaneous implantable cardioverter-defibrillator placement in a patient with dextrocardia, tetralogy of Fallot, and conduction disease

“…Griksaitis et al 14 reported on S-ICD use in 23 children, and Pettit et al 13 reported on its use in 9 children (all on the left side of the thorax), with no difference in rates of pocket hematoma, infection, or inappropriate shocks compared to standard transvenous systems. Use of an S-ICD in a young patient who requires ICD placement is appealing because it avoids the need for transvenous leads, thus potentially averting venous occlusion and the notable risk of lead extraction in the event of lead failure or fracture 15 .…”

Subcutaneous defibrillator implantation in pediatric patients

“…The indications for defibrillation therapy as primary prevention remains controversial, and the decision to implant an ICD in an asymptomatic child has often made it more difficult (5). Improvements in the risk stratification of diseases such as hypertrophic cardiomyopathy and recognition of genetic disorders such as long-QT syndrome and the number of pediatric patients selected for defibrillator implantation have increased over the years (4).…”

“…Subcutaneous array leads with an abdominally placed active can gives an option for the implantation of these devices in infants and patients with a limited venous access, such as repaired congenital heart disease, or loss of venous access, such as thrombosis, and preserved vasculature and reduced lead-related complications, which is frequently observed during childhood (5). There is no clear methodology for the implantation of defibrillator systems, particularly in small children and infants.…”

Learning From Implantable Cardioverter-Defibrillator Leads in Children

“…However, although smaller leads for smaller people may be nice, they are clearly not essential. Perhaps subcutaneous ICD systems can improve the set of options available for younger patients or result in superior performance, 8 but rigorous trials are needed, 9 and trials are currently underway. Delaying the initial implantation of a transvenous system may have significant benefit greater than just the actuarial number of years.…”