Minimally invasive percutaneous pericardial ICD placement in an infant piglet model: Head-to-head comparison with an open surgical thoracotomy approach

BACKGROUND

Epicardial implantable cardioverter-defibrillator (ICD) placement in infants, children, and patients with complex cardiac anatomy requires an open surgical thoracotomy and is associated with increased pain, longer length of stay, and higher cost.

OBJECTIVE

The purpose of this study was to compare an open surgical epicardial placement approach with percutaneous pericardial placement of an ICD lead system in an infant piglet model.

METHODS

Animals underwent either epicardial placement by direct suture fixation through a left thoracotomy or minimally invasive pericardial placement with thoracoscopic visualization. Initial lead testing and defibrillation threshold testing (DFT) were performed. After the 2-week survival period, repeat lead testing and DFT were performed before euthanasia.

RESULTS

Minimally invasive placement was performed in 8 piglets and open surgical placement in 7 piglets without procedural morbidity or mortality. The mean initial DFT value was 10.5 J (range 3-28 J) in the minimally invasive group and 10.0 J (range 5-35 J) in the open surgical group (P = .90). After the survival period, the mean DFT value was 12.0 J (range 3-20 J) in the minimally invasive group and 12.3 J (range 3-35 J) in the open surgical group (P = .95). All lead and shock impedances, R-wave amplitudes, and ventricular pacing thresholds remained stable throughout the survival period.

CONCLUSION

Compared with open surgical epicardial ICD lead placement, minimally invasive pericardial placement demonstrates an equivalent ability to effectively defibrillate the heart and has demonstrated similar lead stability. With continued technical development and operator experience, the minimally invasive method may provide a viable alternative to epicardial ICD lead placement in infants, children, and adults at risk of sudden cardiac death.

Video-assisted pericardioscopic surgery for epimyocardial lead implantation

PURPOSE

Video-assisted pericardioscopic surgery (VAPS) for epimyocardial lead implantation has demonstrated positive acute results concerning the safety and degree of freedom inside the pericardium. We evaluated the employment of a newly developed trocar for pericardioscopy with regard to long-term effects and feasibility of reoperation.

DESCRIPTION

Eight adult sheep were divided into three groups. In two animals, VAPS was used exclusively. All other animals received four small-caliber epicardial leads through VAPS. After 6 and 12 months (n = 3 each), reoperation was conducted for reevaluation of entry site, intrapericardial adhesions, lead position, and morphology of the implantation site.

EVALUATION

Reentry close to the previous entry site proves unproblematic. Adhesions were mild to moderate in the immediate area of the implanted leads. Throughout the follow-up, pacing parameters were satisfactory. Lead dislodgement occurred in 1 of 24 leads. The deployment of small-caliber flexible endoscopes through the new trocar provided sufficient navigation, stability, and maneuverability.

CONCLUSIONS

Reoperation from the same subxiphoid approach proved feasible. Lead removal and reimplantation were feasible at both 6 months and 12 months after initial implantation. The intrapericardial adhesions caused by VAPS alone are mild.