Implantable Cardioverter-Defibrillator Insertion in Congenital Heart Disease Without Transvenous Access to the Heart

Cardiac Implantable Electronic Devices in the Fontan Patient

As a result of remarkable progress in operative techniques and cardiology care during childhood, Fontan patients continue to age and require team-based multidisciplinary expertise to manage complications encountered in adulthood. They face particular challenges in terms of altered hemodynamic stressors, cardiac and hepatic failure, and arrhythmias. Arrhythmias in Fontan patients are highly prevalent and associated with underlying anatomy, surgical technique, and postoperative sequelae. Diagnostic tools, treatments, and device strategies for arrhythmias in Fontan patients should be adapted to the specific anatomy, type of surgical repair, and clinical status. Great strides in our understanding of arrhythmia mechanisms, options and techniques to obtain access to relevant cardiac structures, and application of both old and new technologies have contributed to improving cardiac implantable electronic device (CIED) therapies for this unique population. In this state-of-the-art review, we discuss the various arrhythmias encountered in Fontan patients, their diagnosis, and options for treatment and prevention, with a focus on CIEDs. Throughout, access challenges particular to the Fontan circulation are considered. Recently developed technologies, such as the sub-cutaneous implantable cardioverter defibrillator carry the potential to be transformative but require awareness of Fontan-specific issues. Moreover, new leadless pacing technology represents a promising strategy that may soon become applicable to Fontan patients with sinus node dysfunction. CIEDs are essential tools in managing Fontan patients but the complex clinical scenarios that arise in this patient population are among the most challenging for the congenital electrophysiologist.

Novel approach to intracardiac defibrillator placement in patients with atriopulmonary Fontan: Ventricular defibrillation with an atrial positioned ICD lead

INTRODUCTION

The Fontan procedure, used to palliate univentricular physiology, eliminates direct venous access to the ventricle and complicates implantable cardioverter-defibrillator (ICD) placement.

METHODS AND RESULTS

We describe two patients with Fontan palliation who underwent a novel transvenous approach to ICD placement. The approach uses a transvenous bipolar lead placed in a coronary sinus branch for ventricular sensing, and a defibrillation lead placed in the right atrium for atrial sensing and ventricular defibrillation.

CONCLUSION

Transvenous ICD implantation is possible in some patients with an atriopulmonary Fontan. This approach avoids a redo sternotomy for epicardial leads and excludes the need for lead placement in the systemic circulation.

Cardiac resynchronization and implantable defibrillators in adults with congenital heart disease

Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICDs) are well-established therapies for adult patients with heart failure that have been shown to improve morbidity and mortality. However, the benefits and indications for use in adults with congenital heart disease (ACHD) are less defined with no significant large prospective studies in this population. There are, however, multiple retrospective studies that demonstrate the efficacy of these devices in the ACHD population. These indicate a role for both CRT and ICDs in select patients with ACHD. The clinician and patient must balance the risks and benefits, summarized in complex evidence that reflects the heterogeneity of the ACHD patient group, and apply them in a patient-specific manner to optimize the utility of CRT and ICDs.

Implantable Cardioverter-defibrillators in Adult Congenital Heart Disease

With improved surgical techniques and medical therapies, many patients who are born with complex congenital heart defects are now living well into adulthood. As these patients age, an increasingly common cause of mortality is sudden cardiac death (SCD) from ventricular tachyarrhythmias. The implantable cardioverter-defibrillator (ICD) is a therapy with the ability to prevent some of these deaths; however, there are many diagnostic and technical challenges that remain in the congenital heart disease (CHD) population. We performed a literature review, searching PubMed for articles that examined the role of ICDs in CHD. We herein present the evidence for when to place an ICD in CHD patients, stratified by subtype as relevant. Then, we discuss the technical challenges and complications that are unique to this patient population. We conclude that, despite active work in the area, more research is needed given the small event rates and clinical variability within CHD populations.

Implantable cardioverter-defibrillators in congenital heart disease

Implantable cardioverter-defibrillators (ICD) have an important role in reducing sudden cardiac death in patients with congenital heart disease (CHD); however, the benefit of ICDs needs to be weighed up against both short-term and long-term adverse effects, which are difficult to evaluate in the heterogeneous CHD population. A tailored approach, taking into account risk stratification and patient-specific factors, is needed to select the most appropriate strategy. This review discusses primary and secondary ICD indications, implantation approaches and long-term follow-up. Recent publications have shed light on the concerns of system longevity, lead extractions, inappropriate shocks and impact on the quality of life. All of these factors require consideration prior to commitment to this long-term treatment strategy.

New Technique for Surgical Epicardial Implantation of a Cardioverter-Defibrillator in Children and Adults With Congenital Heart Disease

BACKGROUND

We assessed a surgical technique for implanting a cardioverter-defibrillator. The indications for cardioverter-defibrillator implantation in pediatric patients and adults with congenital heart disease are relatively specific and require multidisciplinary discussion regarding implantation modalities. We coupled the positioning of two coils sutured to the pericardium with an implantable cardioverter-defibrillator device inserted within a supradiaphragmatic pocket in a population of children and adults with congenital heart disease.

METHODS

Thirteen consecutive patients, either children or adults with congenital heart disease, underwent the implantation of a single-chamber implantable cardioverter-defibrillator in our center. All patients were systematically followed at 3, 6, and 12 months after implantation.

RESULTS

Patients were mainly male (n = 9, 69%), and mean age was 21 ± 12 years. Median follow-up was 13 months. All patients underwent surgery without acute complication. One patient needed a second surgery because of defibrillation coils fracture. Neither infectious complication nor inappropriate shock was noted. There were two appropriate shocks in 1 patient.

CONCLUSIONS

This new technique for surgical epicardial implantation of a cardioverter-defibrillator in children and adults with congenital heart disease is safe and feasible. These results should be confirmed by prospective studies with long-term follow-up.

Transvascular Implantation of an Implantable Cardioverter-Defibrillator in a Patient Who has Undergone One-and-a-Half Ventricle Repair

Implantable cardioverter-defibrillator (ICD) therapy is acknowledged as a valid treatment method for the effective prevention of sudden cardiac death, which is a major cause of mortality in adult congenital heart disease patients. But ICD implantation by the conventional transvascular approach is not always possible in patients who have undergone palliative surgery due to congenital and structural heart disease. Here, we report a case in which an ICD was transvascularly implanted in an arrhythmogenic right ventricular cardiomyopathy patient who had undergone a one-and-a-half ventricle repair.