Impact of routine right parasternal electrocardiographic screening in assessing eligibility for subcutaneous implantable cardioverter-defibrillator

Comparison of Preoperative ECG Screening and Device-Based Vector Analysis in Patients Receiving a Subcutaneous Implantable Cardioverter-Defibrillator

Background and Objectives: Subcutaneous implantable cardioverter-defibrillators (S-ICDs) provide protection against sudden cardiac death from outside the cardiovascular system. ECG screening is a prerequisite for implantation, but the reproducibility of its results post-operatively in the device is only partial. We aimed to compare the results of ECG screening with device-based sensing vector analysis. Materials and Methods: We screened the hospital records of all S-ICD recipients in our clinic. All of them had pre-operative ECG screening performed (primary, secondary, and alternate vectors). The results were compared with device-based vector analysis to determine the relation of the pre- and post-operative vector availability. Results: Complete ECG screening and device-based vector analysis were obtained for 103 patients. At least two acceptable vectors were found in 97.1% of the patients pre-operatively and in 96.1% post-operatively. When comparing vectors in terms of agreement (OK or FAIL) pre- and post-operatively, in 89.3% of the patients, the result for the primary vector was the same in both situations; for the secondary, it was in 84.5%, and for the alternate, it was in 74.8% of patients, respectively. In 55.3% of patients, all three vectors were labeled the same (OK or FAIL); in 37.9%, two vectors had the same result, and in 6.8%, only one vector had the same result pre- and post-operatively. The number of available vectors was the same pre- and post-operatively in 62.1% of patients, while in 15.5%, it was lower, and in 22.3% of patients, it was higher than observed during screening. Conclusions: Routine clinical pre-operative screening allowed for a good selection of candidates for S-ICD implantation. All patients had at least one vector available post-operatively. The final number of vectors available in the device-based analysis in most patients was at least the same (or higher) than during screening. The repeatability of the positive result for a single vector was high.

Subcutaneous Implantable Cardioverter Defibrillators in Pediatrics and Congenital Heart Disease

Subcutaneous implantable cardioverter defibrillators (S-ICDs) are being used with increased frequency in children and patients with congenital heart disease. Vascular access complexities, intracardiac shunts, and specific anatomies make these devices particularly appealing for some of these patients. Alternative screening, implantation, and programming techniques should be considered based on patient size, body habitus, anatomy, procedural history, and preference. Appropriate and inappropriate shock rates are generally comparable to those seen with transvenous devices. Complications such as infection can occur, although their severity is likely to be less than that seen with transvenous devices. Technical advances are likely to further broaden S-ICD applicability.

S-ICDs: advantages and opportunities for improvement

INTRODUCTION

The subcutaneous implantable cardioverter defibrillator (S-ICD) is currently in its third generation and has been adopted in guidelines and in mainstream clinical practice. Considerable improvements have been made since the introduction of this device over a decade ago.

AREAS COVERED

A literature search was undertaken in Pubmed on articles relating to the S-ICD.

EXPERT OPINION

The therapy has been proven to be safe and effective and is a valuable option in selected patients. Nevertheless, there remain many shortcomings of the S-ICD which are discussed in this review, and which hopefully will be addressed by future generations of the device.

Eligibility for subcutaneous implantable cardioverter-defibrillator in adults with congenital heart disease

Aims

Patients with adult congenital heart disease (ACHD) carry an increased risk for sudden cardiac death. Implantable cardioverter‐defibrillator (ICD) therapy may be challenging in these patients due to anatomical barriers, repeated cardiac surgery, or complicated transvenous access. Thus, the subcutaneous ICD (S‐ICD) can be a promising alternative in this patient population. Patients with ACHD show significant electrocardiogram (ECG) abnormalities, which could affect S‐ICD sensing because it depends on surface ECG.

Methods and results

One hundred patients with ACHD were screened for S‐ICD eligibility. Standard ECG‐based screening test and automated S‐ICD screening test were performed in all patients. Sixty‐six patients (66%) were male. Underlying congenital heart disease (CHD) was mainly CHD of great complexity (71%) and moderate complexity (29%), including repaired tetralogy of Fallot (20%), which was the most common entity. Thirty‐seven patients (37%) already had a pacemaker (23%) or ICD (14%) implanted. Automated screening test identified 83 patients (83%) eligible for S‐ICD implantation in either left parasternal position (78%) or right parasternal position (75%). Absence of sinus rhythm, QRS duration, and a paced QRS complex were associated with S‐ICD screening failure in univariate analysis. Receiver operating characteristic curve and multivariate analysis revealed a QRS duration ≥148 ms as the only independent predictor for S‐ICD screening failure.

Conclusions

Patients with ACHD show satisfactory eligibility rates (83%) for S‐ICD implantation utilizing the automated screening test, including patients with CHD of high complexity. S‐ICD therapy should be considered with caution in ACHD patients with a QRS duration ≥148 ms and/or need for ventricular pacing.

Pediatric SubQ-ICD implantation, a single center review of the inter-muscular technique

INTRODUCTION

Pediatric patients with cardiomyopathies are at risk for sudden death and may need implantable cardioverter defibrillators (ICD's), but given their small size and duration of use, children are at increased risk for complications associated with ICD use. The subcutaneous ICD presents a favorable option for children without pacing indications. Unfortunately, initial pediatric studies have demonstrated a high complication rate, likely due to the 3-incision technique employed.

MATERIAL AND METHODS

Patients with ICD but no pacing indication were retrospectively reviewed after implantation of subcutaneous ICD via the two-incision technique. In half of the patients, 10-J impedance test was also performed to compare with impedance obtained after defibrillation threshold testing with 65-J.

RESULTS

Twelve patients were included. The median age was 14 years (range 10-16 years) with eight males included (72.7%). The median weight was 55 kg (range 29 kg-75.1 kg). Follow-up had a median of 11.5 months (range 2-27 months). The median body mass index was 18.4 kg/m squared (range 15.5-27.9 kg/m squared). One patient suffered a minor complication after tearing off the incisional adhesive strips early and required a non-invasive repair in clinic. Shock impedance had a median of 55 J (range 48-68 J). There was one appropriate shock/charge and no inappropriate shocks during follow-up.

CONCLUSION

The two-incision, intermuscular technique appears to have a lower acute complication rate than prior reports, in our cohort of 12 pediatric patients.