Europace Advance Access originally published online on April 17, 2008
Europace 2008 10(6):736-737; doi:10.1093/europace/eun096
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ICDs
New transvenous implantable cardioverter defibrillator configuration for use after tricuspid valve surgery
Department of Cardiology, The Texas Heart Institute at St Luke's Episcopal Hospital and Baylor College of Medicine, 6624 Fannin, Suite 2780, Houston, TX 77030, USA
Manuscript submitted 1 February 2008. Accepted after revision 23 March 2008.
* Corresponding author. Tel: +1 713 790 9401; fax: +1 713 790 0353. E-mail address: jalopez{at}bcm.tmc.edu or atownley{at}heart.thi.tmc.edu
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Abstract |
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A 57-year-old patient with a tricuspid valve (TV) prosthesis underwent successful atrioventricular pacing and internal defibrillation via a totally transvenous approach without crossing the TV. Ventricular pacing and sensing were obtained with a bipolar lead in the lateral cardiac vein. Internal defibrillation was obtained with a coil lead in the middle cardiac vein and an ‘active can’ pulse generator in the left infraclavicular region.
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Introduction |
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Pacing and defibrillator therapy after tricuspid valve (TV) replacement remain a challenge. For years, we and others have placed endocardial right ventricular (RV) leads through bioprosthetic valves, but valve damage is possible, particularly during lead removal, and the lead may fracture at the tricuspid site.1
In the presence of a mechanical valve, this method is contraindicated. We describe a case in which total transvenous cardiac pacing and defibrillation were achieved without crossing the TV, thus avoiding epicardial or endocardial transvalvular lead placement. |
Case report |
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In December 2001, a 51-year-old man underwent TV replacement with a porcine prosthesis (31 mm Mosaic® valve, Medtronic, Minneapolis, MN, USA) for severe regurgitation and dilation of the TV annulus and right ventricle. A Maze III procedure was performed for atrial fibrillation. Pre-operatively, the left ventricular (LV) ejection fraction was 30%, and no coronary disease was evident.
Post-operatively, no atrial activity was evident, and multiple episodes of polymorphic ventricular tachycardia and fibrillation required cardioversion (days 3 and 5), despite an adequate ventricular-paced rhythm. On day 7, a dual-chamber pacemaker/defibrillator was implanted (MaximoTM DR, Model 7278, Medtronic, Minneapolis, MN, USA). The atrial lead (CapSureFix® Novus Model 5076, Medtronic, Minneapolis, MN, USA) was placed in the low interatrial septum (the only site with excitable tissue and electrographic signals), and a pacing/defibrillation lead (SprintTM 6943, Medtronic, Minneapolis, MN, USA) was placed into the right ventricle through the prosthetic valve. The ventricular defibrillation threshold (DFT) was 20 J.
The patient did well until September 2004, when he was admitted for syncope and recurrent internal shocks because of ventricular oversensing, which inhibited ventricular pacing and caused inappropriate detection of ventricular fibrillation. The V–V counter detected more than 4000 episodes of <120 ms. He underwent laser-assisted removal of the ventricular lead, followed by placement of a new lead (Sprint 6943, Medtronic, Minneapolis, MN, USA), and two-dimensional echocardiography showed normal prosthetic valve function.
In February 2006, the patient experienced five inappropriate shocks because of ventricular oversensing. Impedance was 1000
in the RV pacing lead, 57 in the superior vena cava (SVC), and 44 in the RV coils. To avoid tricuspid damage, a bipolar lead (Attain® 4184, Medtronic, Minneapolis, MN, USA) was placed in the inferolateral vein for pacing and sensing, and defibrillation was obtained with the long-term RV coil. He remained asymptomatic, and bimonthly lead evaluations showed SVC and RV coil impedances of 40–50.
In September 2007, during a routine evaluation, the SVC and RV coils showed an impedance of >200. The patient again underwent laser-assisted removal of the RV lead. Transoesophageal echocardiography showed normal prosthesis function. To avoid lead placement across the prosthesis, we selectively catheterized the middle cardiac vein (Figure 1) and delivered a 7 F lead (Sprint Fidelis® 6949, Medtronic, Minneapolis, MN, USA) through a modified Attain® sheath (Medtronic, Minneapolis, MN, USA). The screw was not expanded, and the pacing/sensing connector was capped. The atrial lead, LV lead, and coils were connected to an implantable cardioverter defibrillator (Maximo DR 7278, Medtronic, Minneapolis, MN, USA) (Figure 2). Ventricular fibrillation was induced twice, and successful defibrillation was obtained at 20 J with 47 of impedance. At 30 and 90 days, the patient remained asymptomatic.
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Comment |
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The standard epicardial defibrillation system comprises two patch electrodes or one patch and an SVC coil. Without other surgical procedures, this approach entails a mortality of 3.3% and a lead-failure rate of 20%.2
Recently, to avoid the use of epicardial patches, coil leads designed for subcutaneous use have been placed in the pericardial space of some patients with high DFTs3 and in paediatric patients who require defibrillator therapy.4
Placement of defibrillating coils in the coronary sinus is a safe, effective means of transvenous defibrillation.5 Usually, the lead is placed in the main sinus, and defibrillation is obtained between the RV coil and coronary sinus coil, significantly reducing the DFT by including more of the LV myocardium in the current vector. When the right ventricle is not accessible, a coil may be placed in the middle cardiac vein. Given the low probability of lead migration, the lead would contact the inferior cardiac surface and septum, and the right and left ventricles would be included in the current vectors (distal coil to ‘can’ and/or to SVC coil). Ventricular pacing and sensing could be obtained with bipolar leads designed for LV pacing.
One concern is the degree of complexity and possible risk if lead removal is required after long-term implantation. Because of adhesions in the coronary sinus or its branches, tears might occur during lead removal. The clinician should compare this risk with that of a thoracotomy, particularly in patients with multiple previous cardiac operations.
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References |
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[1] Clarke B, Jones S, Gray HH, Rowland E. The tricuspid valve: an unusual site of endocardial pacemaker lead fracture. Pacing Clin Electrophysiol (1989) 12:1077–9.[CrossRef][Medline]
[2] Lehmann MH, Steinman RT, Meissner MD. Operative mortality and morbidity with ICD therapy. In: Implantable Cardioverter-Defibrillators—Naccarelli GV, Veltri EP, eds. (1993) Boston, MA: Blackwell Scientific Publications. 103–5.
[3] Molina JE, Benditt DG. An epicardial subxiphoid implantable defibrillator lead: superior effectiveness after failure of standard implants. Pacing Clin Electrophysiol (2004) 27:1500–6.[CrossRef][Medline]
[4] Stephenson EA, Batra AS, Knilans TK, Gow RM, Gradaus R, Balaji S, et al. A multicenter experience with novel implantable cardioverter defibrillator configurations in the pediatric and congenital heart disease population. J Cardiovasc Electrophysiol (2006) 17:41–6.[CrossRef][Web of Science][Medline]
[5] Bardy GH, Hofer B, Johnson G, Kudenchuk PJ, Poole JE, Dolack GL, et al. Implantable transvenous cardioverter-defibrillators. Circulation (1993) 87:1152–68.
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