Entirely Subcutaneous Implantable Defibrillator
2014; Lippincott Williams & Wilkins; Volume: 7; Issue: 2 Linguagem: Inglês
10.1161/circep.113.001320
ISSN1941-3149
AutoresLaura Cipolletta, Mario Luzi, Luca Piangerelli, Federico Guerra, Alessandro Capucci,
Tópico(s)Cardiomyopathy and Myosin Studies
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 7, No. 2Entirely Subcutaneous Implantable Defibrillator Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBEntirely Subcutaneous Implantable DefibrillatorSafest Option in a Young Girl With Ventricular Tachycardia and Ebstein Anomaly Laura Cipolletta, MD, Mario Luzi, MD, Luca Piangerelli, MD, Federico Guerra, MD and Alessandro Capucci, MD Laura CipollettaLaura Cipolletta From Cardiology and Arrhythmology Clinic, Marche Polytechnic University, Ancona, Italy. , Mario LuziMario Luzi From Cardiology and Arrhythmology Clinic, Marche Polytechnic University, Ancona, Italy. , Luca PiangerelliLuca Piangerelli From Cardiology and Arrhythmology Clinic, Marche Polytechnic University, Ancona, Italy. , Federico GuerraFederico Guerra From Cardiology and Arrhythmology Clinic, Marche Polytechnic University, Ancona, Italy. and Alessandro CapucciAlessandro Capucci From Cardiology and Arrhythmology Clinic, Marche Polytechnic University, Ancona, Italy. Originally published1 Apr 2014https://doi.org/10.1161/CIRCEP.113.001320Circulation: Arrhythmia and Electrophysiology. 2014;7:358–359IntroductionCase ReportA 16-year-old female patient with Ebstein anomaly was admitted to the hospital for 2 episodes of hemodynamically unstable ventricular tachycardia (VT; Figure 1). Two months earlier, she had undergone surgical tricuspid valve replacement with a biological prosthetic valve and cavopulmonary anastomosis (Figure 2). Both VT episodes were treated with external direct current cardioversion, and the patient was then referred to our center to attempt VT ablation. Unfortunately, the fact that the right ventricle (RV) was papyraceous and the free ventricular wall was thin would have exposed the patient to a high risk of catheter perforation. Because transvenous implantable cardioverter-defibrillator (ICD) implantation had the same risk of cardiac perforation, and access to the right cardiac chambers had been made unfeasible by cavopulmonary anastomosis, subcutaneous (S)-ICD implantation was considered. In assessing the patient's adequacy for S-ICD implantation, the morphology of the QRS was screened to avoid T wave oversensing (Figure 3). Because of the bizarre morphology of the QRS attributable to severe dilatation of the RV, QRS screening was performed with the left arm electrode placed to the right side of the xiphoid process (Figure 4). Under local anesthesia and conscious sedation, the catheter was inserted subcutaneously from the pocket in the left midaxillary region to the right side of the xiphoid process. The tip was then advanced up to the manubrio-sternal junction, 1 cm to the right of the midsternal line. At the end of the procedure, a defibrillation test was performed: clinical VT was induced, correctly sensed, and treated after 12.5 seconds with a 65 J shock (conventional polarity configuration). On 2-month follow-up examination, the patient did not have any complications, and no significant events were recorded.Download figureDownload PowerPointFigure 1. A 12-lead ECG of hemodynamically unstable ventricular tachycardia.Download figureDownload PowerPointFigure 2. Cardiac magnetic resonance. A, Sagittal image of the heart. B, Transversal image of the heart. AR indicates anterior right; FR, foot right; HL, head left; LV, left ventricle; MRN, magnetic resonance number; PL, posterior left; and RV, right ventricle.Download figureDownload PowerPointFigure 3. Screening ECG at 10 mm/mV in sitting (A) and in supine (B) positions. ECG at both positions was considered adequate to predict a good vector/posture combination.Download figureDownload PowerPointFigure 4. Chest x-ray film. A, Posterior-anterior projection: blue arrows show correct shock vector with catheter placed at the right side of the sternum. Yellow dotted arrows show shock vector with the catheter in the standard position (left parasternal line). B, Lateral projection.DiscussionTo our knowledge, this is the first case of S-ICD implantation reported in a patient with Ebstein anomaly and cavopulmonary anastomosis. In congenital heart defect (CHD), the impaired RV might create an arrhythmogenic substrate.1 Traditional transvenous ICD implantation is associated with infectious complications and difficulty in maintaining long-term lead integrity.2,3 Implanting an S-ICD in patients with CHD may help to overcome most of the acute and chronic complications of transvenous ICD implantation.4 The S-ICD is better able to discriminate nonventricular arrhythmias than most transvenous systems, and its rate of inappropriate shocks is lower.4 In our case, despite the bizarre morphology of the QRS and its repolarization, correct sensing was achieved. The peculiarity of this case is that the defibrillation catheter was placed to the right of the sternum because positioning the vector to the left of the sternum, as usually suggested, would have created a shock vector that covered only a small portion of the heart because of the severe dilatation of the right chambers. Positioning the catheter on the right side of the sternum provided sufficient coverage of the heart and yielded correct and effective sensing and treatment of ventricular arrhythmias (Figure 4).ConclusionsS-ICD can be safely implanted in patients with CHD not requiring pacing in whom it is impossible to reach the right chambers. In the event of severe dilatation of the right chambers, placement of the S-ICD catheter along the right parasternal line can enable ventricular arrhythmias to be treated more correctly.DisclosuresA. Capucci received a fee from Boston Scientific in 2013. The other authors report no conflicts.FootnotesCorrespondence to Laura Cipolletta, MD, Cardiology and Arrhythmology Clinic, Marche Polytechnic University, Via Conca, 71, 60126 Ancona, Italy. E-mail [email protected]References1. Basso C, Frescura C, Corrado D, Muriago M, Angelini A, Daliento L, Thiene G. Congenital heart disease and sudden death in the young.Hum Pathol. 1995; 26:1065–1072.CrossrefMedlineGoogle Scholar2. Shah MJ. Implantable cardioverter defibrillator-related complications in the pediatric population.Pacing Clin Electrophysiol. 2009; 32(Suppl 2):S71–S74.CrossrefMedlineGoogle Scholar3. Berul CI, Van Hare GF, Kertesz NJ, Dubin AM, Cecchin F, Collins KK, Cannon BC, Alexander ME, Triedman JK, Walsh EP, Friedman RA. Results of a multicenter retrospective implantable cardioverter-defibrillator registry of pediatric and congenital heart disease patients.J Am Coll Cardiol. 2008; 51:1685–1691.CrossrefMedlineGoogle Scholar4. Bardy GH, Smith WM, Hood MA, Crozier IG, Melton IC, Jordaens L, Theuns D, Park RE, Wright DJ, Connelly DT, Fynn SP, Murgatroyd FD, Sperzel J, Neuzner J, Spitzer SG, Ardashev AV, Oduro A, Boersma L, Maass AH, Van Gelder IC, Wilde AA, van Dessel PF, Knops RE, Barr CS, Lupo P, Cappato R, Grace AA. An entirely subcutaneous implantable cardioverter-defibrillator.N Engl J Med. 2010; 363:36–44.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Balaji S, Mandapati R and Webb G (2019) Ebstein Anomaly With Atrial Tachycardia Arrhythmias in Adult Congenital Heart Disease, 10.1016/B978-0-323-48568-5.00007-X, (53-58), . Moore J, Shannon K, Gallotti R, McLeod C, Chiriac A, Walsh E, Sreeram N, Patel A, De Groot N, von Alvensleben J, Balaji S, Frankel D, Miyake C, Perry J and Shivkumar K (2018) Catheter Ablation of Ventricular Arrhythmia for Ebstein's Anomaly in Unoperated and Post-Surgical Patients, JACC: Clinical Electrophysiology, 10.1016/j.jacep.2018.05.009, 4:10, (1300-1307), Online publication date: 1-Oct-2018. April 2014Vol 7, Issue 2 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.113.001320PMID: 24736427 Manuscript receivedNovember 25, 2013Manuscript acceptedDecember 24, 2013Originally publishedApril 1, 2014 Keywordstachycardia, ventriculardeath, sudden, cardiacPDF download Advertisement SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-DefibrillatorComputerized Tomography (CT)Congenital Heart DiseaseElectrophysiology
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