Pectoral cardioverter defibrillators: comparison of prepectoral and submuscular implantation techniques

Efficacy and safety of different exercises in preventing cardiac implantable electronic device-related shoulder impairment

BACKGROUND

Shoulder impairment on the implant-side is common after cardiac implantable electronic device (CIED) implantation. The aim of this study was to compare the efficacy and safety of the pendulum exercise (PE) and stretching & strengthening exercises (SSE) in preventing postimplantation shoulder impairment.

METHODS

This prospective, randomized study collected data from 89 patients, including 30 in a control group, 31 in a PE group, and 28 in a SSE group. Shoulder functions on the implant-side were evaluated by grip strength (GS), range of motion (ROM), Visual Analog Scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and 36-Item Short-Form Survey (SF-36).

RESULTS

Shoulder median flexion and abduction ROM were significantly improved two-month postimplantation compared to two-week postimplantation in PE (156±11 vs. 146±10, p = .002; 147±9 vs. 136±9, p = .001, respectively) and SSE (158±13 vs. 147±11, p = .003; 149±13 vs. 138±9, p = .002, respectively) groups, but not in the control group. Two months after implantation, the two exercise groups showed no significant differences in any assessment. Compared with the PE and SSE groups, the control group had significantly lower GS (p = .012 and p = .002, respectively) and SF-36 physical component summary (p = .007 and p = .003, respectively) and significantly higher VAS (p = .003 and p = .001, respectively) and QuickDASH (p = .002 and p = .005, respectively) scores two-month postimplantation.

CONCLUSIONS

PE and SSE for the ipsilateral upper arm starting two-week after CIED implantation provided similar benefits in preserving shoulder girdle muscle strength, maintaining shoulder motion, relieving shoulder pain, preventing shoulder injury, and improving quality of life, without the risk of lead dislodgement. This article is protected by copyright. All rights reserved.

Predictors of shoulder limitations and disability in patients with cardiac implantable electronic devices: Importance of device size

BACKGROUND

Generator-induced shoulder impairment is a common complication of cardiac implantable electronic device (CIED) implantation. Although implantable cardioverter-defibrillators (ICDs) have become smaller in size, they are still bigger than pacemakers (PMs). This study aimed to investigate the effects of single-chamber PM and ICD sizes on shoulder function.

METHODS

This retrospective study included 200 consecutive patients, of whom 123 had PMs and 77 had ICDs. The CIED implantation effects on shoulder function, pain, disability, and quality of life (QoL) were evaluated. The range of motion (ROM), Visual Analog Scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and Short Form-36 (SF-36) Health Survey (Physical and Mental Component Summary [PCS and MCS]) were used.

RESULTS

The flexion and abduction range limitation rates were significantly higher in the ICD group than in the PM group (16.9% vs. 7.3%, p = .035 and 19.5% vs. 8.9%, p = .031, respectively). The two groups had similar VAS scores. The median QuickDASH score was significantly higher in the ICD group than in the PM group (8.2 [3.6-19.6] vs. 4.6 [2.6-17.9], p = .034). There were no significant differences in SF-36 components between the two groups. ICD implantation (OR: 1.642, 95% CI: 1.293-2.776; p = .001) and incision length (OR: 1.343, 95% CI: 1.194-2.064; p = .01) were independent predictors of shoulder ROM limitations.

CONCLUSIONS

Reduced device sizes with advancing technology can decrease shoulder functional limitations and disability after implantation. Healthcare professionals should not neglect shoulder evaluations during the pre- and postimplantation periods.

Shoulder Function After Cardioverter-Defibrillator Implantation: 5-Year Follow-up

BACKGROUND

Implantable cardioverter-defibrillator (ICD) represents the main tool for prevention of sudden cardiac death. Different kinds of postimplant complications have been described; however, little is known about shoulder functional impairment and its impact on quality of life.

METHODS

Patients with standard indications for elective prepectoral subcutaneous ICD insertion were enrolled during a 1-year period. The impact of ICD implantation on shoulder motility, pain, general disability, and quality of life was evaluated prospectively at baseline, and after 2 weeks, 3 months, 1 year, and 5 years using the Constant score, the Numeric Pain Rating Scale, the Disabilities of the Arm, Shoulder, and Hand scale, and the Short Form-36 Health Survey questionnaire.

RESULTS

A total of 50 patients underwent insertion of single, dual chamber, or biventricular ICDs. Two weeks after implantation, functional impairment and mild pain were observed in ipsilateral shoulder movements, with a reduction in the Short Form-36 Health Survey score. Shoulder functional impairment improved at the third-month evaluations, with almost normalization at 1-year and 5-year assessments, as well as pain and quality of life.

CONCLUSIONS

Prepectoral subcutaneous ICD implantation may be associated with ipsilateral shoulder functional impairment that regresses partially after 3 months and completely at 1-year and 5-year assessments. The less invasive implantation technique and the relatively small size of modern ICDs, independently from types and volumes, may be relevant to the degree of postimplantation shoulder functional impairment and recovery time. Shoulder function should be assessed at routine checks, especially soon after ICD implantation because of potential functional impairment and subsequent impact on quality of life.

"Real life" longevity of implantable cardioverter-defibrillator devices

BACKGROUND

Manufacturers of implantable cardioverter-defibrillators (ICDs) promise a 5- to 9-year projected longevity; however, real-life data indicate otherwise. The aim of the present study was to assess ICD longevity among 685 consecutive patients over the last 20 years.

HYPOTHESIS

Real-life longevity of ICDs may differ from that stated by the manufacturers.

METHODS

The study included 601 men and 84 women (mean age, 63.1 ± 13.3 years). The underlying disease was coronary (n = 396) or valvular (n = 15) disease, cardiomyopathy (n = 220), or electrical disease (n = 54). The mean ejection fraction was 35%. Devices were implanted for secondary (n = 562) or primary (n = 123) prevention. Single- (n = 292) or dual-chamber (n = 269) or cardiac resynchronization therapy (CRT) devices (n = 124) were implanted in the abdomen (n = 17) or chest (n = 668).

RESULTS

Over 20 years, ICD pulse generator replacements were performed in 238 patients (209 men; age 63.7 ± 13.9 years; ejection fraction, 37.7% ± 14.0%) who had an ICD for secondary (n = 210) or primary (n = 28) prevention. The mean ICD longevity was 58.3 ± 18.7 months. In 20 (8.4%) patients, devices exhibited premature battery depletion within 36 months. Most (94%) patients had none, minor, or modest use of ICD therapy. Longevity was longest for single-chamber devices and shortest for CRT devices. Latest-generation devices replaced over the second decade lasted longer compared with devices replaced during the first decade. When analyzed by manufacturer, Medtronic devices appeared to have longer longevity by 13 to 18 months.

CONCLUSIONS

ICDs continue to have limited longevity of 4.9 ± 1.6 years, and 8% demonstrate premature battery depletion by 3 years. CRT devices have the shortest longevity (mean, 3.8 years) by 13 to 17 months, compared with other ICD devices. These findings have important implications, particularly in view of the high expense involved with this type of electrical therapy.

Subpectoral Implantation of Internal Pulse Generators for Deep Brain Stimulation: Technical Note for Improved Cosmetic Outcomes

BACKGROUND: Deep brain stimulation is increasingly used to treat a variety of disorders. As the prevalence of this technology increases, greater demands are placed on neurosurgical practitioners to improve cosmetic results, maximize patient comfort, and minimize complication rates. We have increasingly employed subpectoral implantation of internal pulse generators (IPGs) to improve patient satisfaction.

OBJECTIVE: To determine the complication rates of subpectorally placed IPGs as compared to those placed in a subcutaneous location.

METHODS: We reviewed a series of 301 patients from a single institution. Complication rates including infection, hematoma, and lead fracture were recorded. Rates were compared for subcutaneously and subpectorally located devices.

RESULTS: Of the records reviewed, we found 301 patients who underwent 308 procedures for initial IPG implantation. Of these, 275 were subpectoral IPG implantation, 19 were infraclavicular subcutaneous implantation, and 14 were subcutaneous implantation in the abdomen. A total of 6 IPG pocket infections occurred, 2 subpectoral and 4 infraclavicular subcutaneous. Of the IPG infections, 2 of the infraclavicular subcutaneous devices had associated erosions. Two patients had their devices relocated from a subpectoral pocket to a subcutaneous pocket in the abdomen due to discomfort. Two patients in the subpectoral group suffered from hematoma requiring evacuation. Two patients in the infraclavicular subcutaneous group had lead fracture occur.

CONCLUSIONS: Subpectoral implantation of deep brain stimulation IPGs is a viable alternative with a low complication rate. This technique may offer a lower rate of infection and wound erosion.

Cardiac pacing and defibrillation in children and young adults

The population of children and young adults requiring a cardiac pacing device has been consistently increasing. The current generation of devices are small with a longer battery life, programming capabilities that can cater to the demands of the young patients and ability to treat brady and tachyarrhythmias as well as heart failure. This has increased the scope and clinical indications of using these devices. As patients with congenital heart disease (CHD) comprise majority of these patients requiring devices, the knowledge of indications, pacing leads and devices, anatomical variations and the technical skills required are different than that required in the adult population. In this review we attempt to discuss these specific points in detail to improve the understanding of cardiac pacing in children and young adults.

Safety and potential cost savings of same-setting electrophysiologic testing and placement of transvenous implantable cardioverter-defibrillators

BACKGROUND

Separately, electrophysiologic study (EPS) and placement of a transvenous implantable cardioverter-defibrillator (ICD) can be performed safely in the majority of patients. The safety and potential cost savings of same-setting procedures have not been evaluated.

HYPOTHESIS

Electrophysiologic study and placement of transvenous ICDs can be performed safely in the same setting at reduced cost.

METHODS

In all. 160 (mean age 65 +/- 10 years, 75% men) and 41 (mean age 66 +/- 11 years, 73% men) consecutive patients who underwent same- versus separate-setting procedures, respectively, were prospectively evaluated.

RESULTS

The two groups had similar clinical characteristics and indications for EPS and ICD therapy. Complications occurred in eight patients (5.0%, 95% confidence interval [CI] 2.3-10.3) who had same-setting procedures (one hypotension during ICD testing, one pocket hematoma, two lead dislodgments, two pneumothoraces, one stroke, and one infection) and in two (4.9%, CI 0.60-16.5) who had separate-setting procedures (one pocket hematoma and one infection). There were no procedure-related deaths or long-term ICD-related complications in either group. The mean time from ICD implantation to hospital discharge was similar in the two groups (2.5 +/- 2.4 vs. 2.7 +/- 2.2 days, p = NS). The combined procedure cost was higher in patients who had separate-setting procedures ($12,403 +/- 1,386 vs. $10,242 +/- 2.256, p = < 0.001). who incurred an additional hospital cost of $2,121 +/- $2,125 for the waiting period (1.7 +/- 1.6 days) between EPS and ICD implantation.

CONCLUSIONS

In patients deemed candidates for ICD therapy based on EPS results, placement of transvenous defibrillators in the same setting as EPS is as safe as separate-setting procedures and, if adopted, could further reduce the cost of providing ICD therapy.

Subpectoral cardioverter-defibrillator implantation using a lateral approach

INTRODUCTION

Third-generation cardioverter-defibrillators have revolutionized management of ventricular tachyarrhythmias. Implantation can be performed in the electro-physiology laboratory, with minimal morbidity. Generator size has shrunk to the point that subcutaneous implantation is feasible and safe, even under local anesthesia. The prepectoral technique, however, is associated with increased mechanical stress to the subcutaneous tissue and can predispose to device erosion or infection. These complications may be avoided by submuscular placement. Among subpectoral techniques, the lateral approach offers unrestricted ability to deploy patches or array electrodes, should the need arise, and may represent the optimal implant technique under some circumstances.

METHODS

We studied 29 male patients, aged 29-78 years, who presented with syncope or sustained ventricular tachycardia, and underwent subpectoral defibrillator implantation under general anesthesia or conscious sedation. All devices were third-generation active can systems with biphasic shock capability. Six dual-chamber defibrillators were used.

RESULTS

Subpectoral implantation was successful in all cases, with an estimated blood loss of 28+/-17 mL and no immediate complications. Except for one patient who developed twiddler's syndrome and ultimately required revision to a subcutaneous pocket, the implant site was tolerated well, and no limitation in the range of motion of the upper limb was observed during 20 months of follow-up.

CONCLUSIONS

Subpectoral implantation using a lateral approach is technically straightforward and can be applied globally, with modest additional resource and equipment requirements. Familiarity with this approach can maximize the likelihood of successful defibrillator implantation in the electrophysiology laboratory.

Two-coil versus single-coil transvenous cardioverter defibrillator systems: comparative data

Two types of new-generation transvenous implantable cardioverter defibrillator (ICD) systems, incorporating a two-coil (62 patients, group 1) versus single-coil (32 patients, group 2) lead system were compared among 94 consecutive patients. The two groups were comparable in age (58 +/- 13 vs 59 +/- 14 years), presenting arrhythmia (ventricular tachycardia versus ventricular fibrillation 77%/21% vs 84%/13%), cycle length of induced VT (294 +/- 4 vs 289 +/- 44 ms), number of unsuccessful antiarrhythmic drugs (1.7 +/- 0.8 vs 1.7 +/- 0.7), and left ventricular ejection fraction (35 +/- 12% vs 34 +/- 9%). Both systems were successfully implanted strictly transvenously in all patients. Biphasic shocks were used in all patients. Active shell devices were used in 79% and 84% patients of groups I and II, respectively (P = NS). Intraoperative testing revealed comparable defibrillation threshold (DFT) values (10.2 +/- 3.7 J in group 1 versus 9.3 +/- 3.6 J in group 2 system), and pacing threshold (0.7 +/- 0.3 vs 0.7 +/- 0.3 V), but R wave amplitude and lead impedance were lower in group 1 (13 +/- 5 vs 16 +/- 5 mV, P = 0.003; and 579 +/- 115 vs 657 +/- 111 ohms, P = 0.002, respectively). Lead insulation break requiring reoperation occurred in one patient with an Endotak lead, and two patients with Transvene leads had initially high DFT with a single one-lead/active can system, which was converted to a two- or three-endocardial-lead/inactive can configuration. We conclude that both single-coil and two-coil transvenous ICD systems were associated with high rates of successful strictly transvenous ICD implantation and a low incidence of lead-related complications. Significant differences were noted in the sensed R wave and lead impedance, probably reflecting the active fixation characteristics of the Transvene lead. However, in order to obviate the sporadic need for implantation of additional endocardial leads, as was the case in two patients in this series, a double-coil lead may be preferable.

Electrophysiologist-implanted transvenous cardioverter defibrillators using local versus general anesthesia

With the advent of smaller biphasic transvenous implantable cardioverter defibrillators (ICDs) and the experience gained over the years, it is now feasible for electrophysiologists to implant them safely in the abdominal or pectoral area without surgical assistance. Throughout the years, general anesthesia has been used as the standard technique of anesthesia for these procedures. However, use of local anesthesia combined with deep sedation only for defibrillation threshold (DFT) testing might further facilitate and simplify these procedures. The purpose of this study was to test the feasibility of using local anesthesia and compare it with the standard technique of general anesthesia, during implantation of transvenous ICDs performed by an electrophysiologist in the electrophysiology laboratory. For over 4 years in the electrophysiology laboratory, we have implanted transvenous ICDs in 90 consecutive patients (84 men and 6 women, aged 58 +/- 15 years). Early on, general anesthesia was used (n = 40, group I), but in recent series (n = 50, group II) local anesthesia was combined with deep sedation for DFT testing. Patients had coronary (n = 58) or valvular (n = 4) disease, cardiomyopathy (n = 25) or no organic disease (n = 3), a mean left ventricular ejection fraction of 35%, and presented with ventricular tachycardia (n = 72) or fibrillation (n = 16), or syncope (n = 2). One-lead ICD systems were used in 74 patients, two-lead systems in 10 patients, and an AVICD in 6 patients. ICDs were implanted in abdominal (n = 17, all in group I) or more recently in pectoral (n = 73) pockets. The DFT averaged 9.7 +/- 3.6 J and 10.2 +/- 3.6 J in the two groups, respectively (P = NS) and there were no differences in pace-sense thresholds. The total procedural duration was shorter (2.1 +/- 0.5 hours) in group II (all pectoral implants) compared with 23 pectoral implants of group I (2.9 +/- 0.5 hours) (P < 0.0001). Biphasic devices were used in all patients and active shell devices in 67 patients; no patient needed a subcutaneous patch. There were six complications (7%), four in group I and two in group II: one pulmonary edema and one respiratory insufficiency that delayed extubation for 3 hours in a patient with prior lung resection, both probably related to general anesthesia, one lead insulation break that required reoperation on day 3, two pocket hematomas, and one pneumothorax. There was one postoperative arrhythmic death at 48 hours in group I. No infections occurred. Patients were discharged at a mean time of 3 days. All devices functioned well at predischarge testing. Thus, it is feasible to use local anesthesia for current ICD implants to expedite the procedure and avoid general anesthesia related cost and possible complications.