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Vidal Margenat A, Zedan A, Schubert S, Gopani S, Hariharan R. Patients with a high defibrillation threshold: Approaches to management. Pacing Clin Electrophysiol 2024; 47:222-232. [PMID: 38291870 DOI: 10.1111/pace.14936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/30/2023] [Accepted: 01/11/2024] [Indexed: 02/01/2024]
Abstract
Implantable cardioverter-defibrillators (ICDs) have revolutionized the prognosis for patients at elevated risk of ventricular tachyarrhythmias. For safety, defibrillation should be effective with a minimum of 10 J below the device's maximum energy. While modern ICDs rarely deliver ineffective shocks in primary prevention, the surge in managing severe heart failure patients has led to an increased number of patients with high defibrillation thresholds (DFTs). This article elucidates the potential causes of high DFT, including clinical factors, lead and device placement, the presence of a Left Ventricular Assist Device (LVAD), prolonged ventricular arrhythmias, shock vectors, waveform tilt, medications, and manufacturer-specific options. We also detail management strategies, highlighting alternative shock coil placements, practical recommendations, and case studies from our institution. Our management algorithm suggests addressing preventable causes, re-evaluating coil positions, considering non-invasive system modifications, upgrading to a higher-capacity device, and adding extra coil(s).
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Affiliation(s)
| | - Ahmed Zedan
- EP Heart, University of Texas, Houston, Texas, USA
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Kaptein YE, Bhatia A, Niazi IK. Shock vector modulation via axillary vein coil in a right-sided implantable cardioverter-defibrillator. HeartRhythm Case Rep 2023; 9:935-938. [PMID: 38204839 PMCID: PMC10774573 DOI: 10.1016/j.hrcr.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Yvonne E. Kaptein
- Center for Advanced Atrial Fibrillation Therapies, Aurora Cardiovascular and Thoracic Services, Aurora St. Luke’s Medical Center, Milwaukee, Wisconsin
| | - Atul Bhatia
- Center for Advanced Atrial Fibrillation Therapies, Aurora Cardiovascular and Thoracic Services, Aurora St. Luke’s Medical Center, Milwaukee, Wisconsin
| | - Imran K. Niazi
- Center for Advanced Atrial Fibrillation Therapies, Aurora Cardiovascular and Thoracic Services, Aurora St. Luke’s Medical Center, Milwaukee, Wisconsin
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Tonko JB, Rinaldi CA. Non-traditional implantable cardioverter-defibrillator configurations and insertion techniques: a review of contemporary options. Europace 2021; 24:181-192. [PMID: 34453529 PMCID: PMC8824518 DOI: 10.1093/europace/euab178] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/01/2021] [Indexed: 11/14/2022] Open
Abstract
Implantable cardioverter-defibrillators (ICDs) have revolutionized the treatment of acquired or inherited cardiac diseases associated with a high risk of sudden cardiac death due to ventricular tachyarrhythmias. Contemporary ICD devices offer reliable arrhythmia detection and discrimination algorithms and deliver highly efficient tachytherapies. Percutaneously inserted transvenous defibrillator coils with pectoral generator placement are the first-line approach in the majority of adults due to their extensively documented clinical benefit and efficiency with comparably low periprocedural implantation risks as well as the option of providing pain-free tachycardia treatment via anti-tachycardia pacing (ATP), concomitant bradycardiaprotection, and incorporation in a cardiac resynchronization therapy if indicated. Yet, expanding ICD indications particularly among younger and more complex patient groups as well as the increasingly evident long-term consequences and complications associated with intravascular lead placements promoted the development of alternative ICD configurations. Most established in daily clinical practice is the subcutaneous ICD but other innovative extravascular approaches like epicardial, pericardial, extra-pleural, and most recently substernal defibrillator coil placements have been introduced as well to overcome shortcomings associated with traditional devices and allow for individualized treatment strategies tailored to the patients characteristics and needs. The review aims to provide practical solutions for common complications encountered with transvenous ICD systems including restricted venous access, high defibrillation/fibrillation thresholds (DFTs), and recurrent device infections. We summarize the contemporary options for non-traditional extravascular ICD configurations outlining indications, advantages, and disadvantages.
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Affiliation(s)
- Johanna B Tonko
- Department of Cardiology, St. Thomas' Hospital, Westminster Bridge Rd, London SE1 7EH, UK.,Department of Cardiovascular Imaging, Arrhythmia Research Group, King's College London, School of Biomedical Engineering & Imaging Sciences, London, UK
| | - Christopher A Rinaldi
- Department of Cardiology, St. Thomas' Hospital, Westminster Bridge Rd, London SE1 7EH, UK.,Department of Cardiovascular Imaging, Arrhythmia Research Group, King's College London, School of Biomedical Engineering & Imaging Sciences, London, UK
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Tonko JB, Blauth C, Rosenthal E, Rinaldi CA. Completely epicardial implantable cardioverter/defibrillator (ICD) and CRT-D systems: A case series and systematic literature review. Pacing Clin Electrophysiol 2021; 44:1616-1630. [PMID: 34287989 DOI: 10.1111/pace.14318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/08/2021] [Accepted: 07/11/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Epicardial ICD systems and CRT-Ds using high voltage coils represent an alternative to transvenous systems in patients without central venous access and prior device complications including infection. OBJECTIVE We present a case series in the adult population of epicardial ICD/CRTD systems using high voltage epicardial coils. We summarize the existing data regarding techniques, efficacy, and safety. METHODS A retrospective board approved medical record review was conducted for all patients undergoing epicardial ICD/CRTD placement at our institution between January 2010 and May 2020. The literature was reviewed for prior published trials, case reports, and case series of epicardial high voltage coil insertions. RESULTS Eleven patients (six female, mean age 48 years) underwent epicardial ICD/CRTD implant including 5/11 completely epicardial CRTD systems. The procedure was performed via median sternotomy in eight patients, left anterior thoracotomy in two patients, and sub-xiphoid approach in one patient. After a mean follow up of 35 months, appropriate successful shocks were delivered in two (18%) patients and no patients received an inappropriate shock. Three of five (60%) patients had volumetric remodeling with CRT with significant improvement of LV EF. Device-related complications requiring a surgical/percutaneous revision or another DFT test occurred in six patients (54%). One patient died during follow up due to refractory heart failure. No cases of epicardial device infection, coronary artery compression, constrictive pericarditis, or erosion of defibrillator coils into intrathoracic organs were reported. No randomized studies comparing safety and efficacy of traditional transvenous or subcutaneous ICD systems and epicardial ICD systems using contemporary high voltage coils were found nor any studies directly comparing epicardial defibrillator patches versus epicardial coils. Thirteen case series and 24 single case reports published between 2004 and 2020 were identified describing in total a heterogenous group of 188 patients with ICD systems incorporating one or more epi- or pericardially positioned shock coils. CONCLUSION The use of epicardial defibrillation coils for ICD/CRT-D is a feasible treatment option for patients with either failed or contraindicated transvenous ICD systems. Dedicated epicardial high voltage leads with integrated pace-sense electrodes and specialized delivery tools for minimal invasive implantations may improve longer term outcomes.
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Affiliation(s)
- Johanna B Tonko
- Cardiothoracic Unit, Guy's and St.Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Christopher Blauth
- Cardiothoracic Unit, Guy's and St.Thomas' NHS Foundation Trust, London, UK
| | - Eric Rosenthal
- Faculty of Life Sciences and Medicine, King's College London, London, UK.,Evelina Children's Hospital, Department of Paediatric Cardiology, St Thomas Hospital, London, UK
| | - Christopher A Rinaldi
- Cardiothoracic Unit, Guy's and St.Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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Rodríguez‐Mañero M, Kreidieh B, Ibarra‐Cortez SH, Álvarez P, Schurmann P, Dave AS, Valderrábano M. Coronary vein defibrillator coil placement in patients with high defibrillation thresholds. J Arrhythm 2019; 35:79-85. [PMID: 30805047 PMCID: PMC6373648 DOI: 10.1002/joa3.12136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/23/2018] [Accepted: 09/05/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Elevated defibrillation threshold (DFT) occurs in 2%-6% of patients undergoing implantable cardioverter defibrillator (ICD) implantation. Adding a defibrillation coil in the coronary sinus (CS) or its branches can result in substantial reductions in the mean DFT. However, data regarding acute success and long-term stability remain lacking. We report our experience with this bailout strategy. METHODS Patients with elevated DFT at implantation (safety margin at implantation <10 J) and those with failed ICD shocks for ventricular arrhythmias (VA) referred for high DFT underwent placement of an additional defibrillation coil in the CS. DFT testing was performed at the completion of the implantation procedure. External potentially reversible factors were excluded. High-output devices were systematically used. RESULTS Four patients with high DFT at implantation and two with several failed shock attempts underwent placement of a defibrillation coil in the CS. Mean age was 41.8 (23-78). They presented a mean LVEF of 21% (15-30), QRS-complex duration of 109.8 milliseconds (87-168), body surface area of 1.96 m2 (1.45-2.58), and a mean R wave of 16.3 mV (8-27). Defibrillation coil implantation in the CS (final shocking configuration of right ventricle as anode and left ventricle (LV) plus can as cathode) was associated with successful DFT testing in all. Three patients had a concomitant LV lead for biventricular pacing. During a mean follow-up of 54.67 months (10-118), two patients experienced successful ICD shocks for VA (one of them also presented inappropriate shocks because of the fast conducting atrial fibrillation). CONCLUSIONS Positioning of a defibrillation coil in the CS can result in a substantial reduction in mean DFT and associates with optimal long-term stability.
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Affiliation(s)
- Moisés Rodríguez‐Mañero
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research InstituteThe Methodist HospitalHoustonTexas
- Cardiology DepartmentComplejo Hospital Universitario de SantiagoSantiago de CompostelaSpain
- IDIS (Instituto para el Desarrollo e Integración de la Salud)Santiago de CompostelaSpain
- CIBERCV (Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares)Santiago de CompostelaSpain
| | - Bahij Kreidieh
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research InstituteThe Methodist HospitalHoustonTexas
| | - Sergio H. Ibarra‐Cortez
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research InstituteThe Methodist HospitalHoustonTexas
| | - Paulino Álvarez
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research InstituteThe Methodist HospitalHoustonTexas
| | - Paul Schurmann
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research InstituteThe Methodist HospitalHoustonTexas
| | - Amish S. Dave
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research InstituteThe Methodist HospitalHoustonTexas
| | - Miguel Valderrábano
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research InstituteThe Methodist HospitalHoustonTexas
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Eckart RE, Hruczkowski TW, Stevenson WG, Epstein LM. Myopotentials Leading to Ventricular Fibrillation Detection After Advisory Defibrillator Generator Replacement. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:1273-6. [PMID: 17100683 DOI: 10.1111/j.1540-8159.2006.00531.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We present an unusual source of oversensing following an internal cardioverter-defibrillator generator change. The early appearance of reproducible myopotentials in the defibrillator sensing channel is usually due to a technical complication at the time of device implantation. Clues such as abrupt impedance change or reproduction with mechanical stimulation can help to localize a problem. Frequently the complication requires reoperation to examine the system. What do you do when everything seems to be working fine?
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Affiliation(s)
- Robert E Eckart
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.
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Affiliation(s)
- Sumeet K Mainigi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, 19104, USA
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Cesario D, Bhargava M, Valderrábano M, Fonarow GC, Wilkoff B, Shivkumar K. Azygos Vein Lead Implantation:. A Novel Adjunctive Technique for Implantable Cardioverter Defibrillator Placement. J Cardiovasc Electrophysiol 2004; 15:780-3. [PMID: 15250862 DOI: 10.1046/j.1540-8167.2004.03649.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
High defibrillation thresholds (DFTs) occasionally are encountered during placement of implantable cardioverter defibrillators (ICDs). There are multiple strategies to lower DFTs in such patients, including reassessment of right ventricular lead position, alteration of the shock waveform, and implantation of subcutaneous arrays. This article describes a novel technique of implanting a high-voltage lead in the azygos vein. This procedure may serve as an adjunctive approach to reduce DFTs. The anatomic location of the azygos vein posterior to the heart provides a suitable shocking vector between the right ventricular electrode, a high-voltage lead placed in the azygos vein, and the ICD can.
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Affiliation(s)
- David Cesario
- UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90095-1679, USA
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Gold MR, Olsovsky MR, DeGroot PJ, Cuello C, Shorofsky SR. Optimization of transvenous coil position for active can defibrillation thresholds. J Cardiovasc Electrophysiol 2000; 11:25-9. [PMID: 10695457 DOI: 10.1111/j.1540-8167.2000.tb00731.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Lead systems that include an active pectoral pulse generator are now standard for initial defibrillator implantations. However, the optimal transvenous lead system and coil location for such active can configurations are unknown. The purpose of this study was to evaluate the benefit and optimal position of a superior vena cava (SVC) coil on defibrillation thresholds with an active left pectoral pulse generator and right ventricular coil. METHODS AND RESULTS This prospective, randomized study was performed on 27 patients. Each subject was evaluated with three lead configurations, with the order of testing randomized. Biphasic shocks were delivered between the right ventricular coil and an active can alone (unipolar), or an active can in common with the proximal coil positioned either at the right atrial/SVC junction (low SVC) or in the left subclavian vein (high SVC). Stored energies at defibrillation threshold were higher for the single-coil, unipolar configuration (11.2 +/- 6.6 J) than for the high (8.9 +/- 4.2 J) or low (8.5 +/- 4.2 J) SVC configurations (P < 0.01). Moreover, 96% of subjects had low (< or = 15 J) thresholds with the SVC coil in either position compared with 81% for the single-coil configuration. Shock impedance (P < 0.001) was increased with the unipolar configuration, whereas peak current was reduced (P < 0.001). CONCLUSION The addition of a proximal transvenous coil to an active can unipolar lead configuration reduces defibrillation energy requirements. The position of this coil has no significant effect on defibrillation thresholds.
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Affiliation(s)
- M R Gold
- Department of Medicine, University of Maryland School of Medicine, Baltimore 21201, USA.
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Abstract
Multiple technologic advances in the implantable cardioverter defibrillator (ICD) have resulted in smaller size, easier implantation, and improved detection, therapy, and stored diagnostic information. Advanced dual-chamber ICDs are currently available that allow dual-chamber rate-responsive pacing with mode switching, enhanced detection algorithms, antitachycardia pacing, low-energy cardioversion, high-energy shocks, and extensive diagnostics. Based on improvements in lead systems and improved energy waveforms, almost all devices are being implanted with nonthoracotomy leads in the pectoralis area. The results of recent clinical trials have expanded indications for the ICD for primary and secondary prevention of sudden cardiac death. With advances in capacitor and battery technology coupled with improved lead systems and waveform resulting in lower defibrillation thresholds, it is likely that lower-output, smaller devices will be developed. In the future, ICDs may have expanded indications and may incorporate physiologic sensors to access hemodynamic significance of arrhythmias and algorithms for prediction and prevention of cardiac arrhythmias.
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Affiliation(s)
- C A Swygman
- New England Medical Center, Boston, MA 02111, USA
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Winter J, Heil JE, Schumann C, Lin Y, Schannwell CM, Michel U, Schipke JD, Schulte HD, Gams E. Effect of implantable cardioverter/defibrillator lead placement in the right ventricle on defibrillation energy requirements. A combined experimental and clinical study. Eur J Cardiothorac Surg 1998; 14:419-25. [PMID: 9845149 DOI: 10.1016/s1010-7940(98)00215-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVES The effect of implantable cardioverter/defibrillator (ICD) lead placement in the right ventricle (RV) on defibrillation efficacy has not been thoroughly investigated. Therefore, the goal of this combined experimental and clinical study was to evaluate the effect of a septal and a non-septal position of the right ventricular endocardial spring lead on defibrillation energy. METHODS In 12 isoflurane-anaesthetized swine and subsequently in 8 patients who underwent ICD implantation, two different positions of the distal spring lead in the RV were investigated in randomized order: non-septal position (free wall of the RV) and septal position (interventricular septum). For each position, separate 50% probability determinations of energy (E50), peak voltage (V50) and peak current (A50) were calculated using the three reversal up/down defibrillation procedure. The E50, V50, A50 and impedance (I) were averaged and compared using the two-sided t-test for paired samples. RESULTS Both the experimental study and the clinical study demonstrated that placing the distal defibrillation lead near to the septum rather than near to the ventricular free wall resulted both in the swine and in the patients in significantly lower E50-31.6%/ - 37.1%, V50-16.1%/-20.9% and A50 -10.0%/ - 24.2%, respectively. Defibrillation impedances were significantly reduced only in the experimental study. CONCLUSIONS Defibrillation efficacy depends on the position of the distal spring electrode in the RV. A septal position significantly reduces the energy requirements compared to a non-septal position. The decrease in energy requirements might be explained by an increase in current flow through the septum and the posterolateral wall of the left ventricle. reserved
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Affiliation(s)
- J Winter
- Department of Thoracic and Cardiovascular Surgery, Heinrich-Heine-University, Duesseldorf, Germany
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