Ultrasound-guided serratus anterior plane block combined with the two-incision technique for subcutaneous ICD implantation

S-ICD Implantation in Secondary Prevention in a Young Patient With Recent Surgically Repaired Pectus Excavatum

We report a case of successful implantation of a subcutaneous implantable cardioverter-defibrillator in a young patient with severe pectus excavatum presenting with out-of-hospital ventricular fibrillation arrest who was recently surgically repaired with a MIRPE-Nuss procedure. No complications in lead positioning were observed, and the device was tested to determine that it functioned properly.

Combined subcutaneous implantable cardioverter defibrillator and pacemaker devices in complex congenital heart disease: a single-center experienced based study

BACKGROUND

Subcutaneous implantable cardioverter defibrillators (S-ICD) are widely accepted therapy in congenital heart disease (CHD) patients at risk of life-threatening ventricular arrhythmias or sudden cardiac death (SCD) when pacing is not required. Occasionally, pacemaker (PM)-dependent CHD patients will subsequently develop an indication for a cardioverter defibrillator. The use of S-ICD in complex CHD patients who have had already PM devices implanted implies some specific considerations, as the safety for these patients in unknown and recommendations among physicians may vary widely.

METHODS

We review the data and studied the indications for S-ICD in complex CHD with previous PM and discuss its usefulness in clinical practice.

RESULTS

From a large cohort of 345 patients enrolled in the S-ICD Monaldi care registry, which encompass all the patients implanted in the Monaldi Hospital of Naples, we considered 11 consecutive complex CHD patients (10M/1F aged 40.4 ±18.4 years) who underwent S-ICD implant after a previous PM implant, from February 2015 to October 2022. Mean follow-up was 25.5 ± 22 months. All the patients showed a good compliance to the device system with no complications (infections or skin erosions).

CONCLUSIONS

In complex CHD with already implanted PM devices, S-ICD implant appears to be a safe alternative to PM upgrading to transvenous ICD system, avoiding abandoned leads or life-threatening lead extraction. However, there are important issues with regard to testing and programming that need to be addressed at the time of implantation.

Utilization of Regional Anesthesia in the Electrophysiology Lab: A Narrative Review

PURPOSE OF REVIEW

The electrophysiology lab is an important source of growth of anesthetic volume as the indications and evidence for catheter ablations and various cardiac implantable electronic devices improve. Paired with this increase in volume is an increasing number of patients with substantial comorbid conditions presenting for their EP procedures. For these patients, the interaction between their comorbidities and traditional anesthesia practices may create the risk of hemodynamic instability, cardiovascular or respiratory complications, and potential need for prolonged post-operative monitoring negatively impacting length of hospital stay.

RECENT FINDINGS

Regional anesthetic techniques, including pectoralis, serratus, and erector spinae plane blocks, offer options for both regional analgesia and surgical anesthesia for a variety of EP procedures. Existing case reports and extrapolations from other areas support these techniques as viable, safe, and effective components of an anesthetic plan. In this article, we will review the development and challenges of various EP procedures and how different regional anesthetic techniques can function as a component of the anesthesia plan.

"Shift and cover technique": conservative management of complications for the rescue of S-ICD subcutaneous implantable defibrillator systems

BACKGROUND

The risk of complications has been shown to be lower with subcutaneous implantable defibrillator (S-ICD) than with conventional ICDs. Given the low frequency of complications, experience of how to manage them is limited. In this paper, we describe generator- and lead-related complications recorded in a series of S-ICD patients, and we propose our conservative approach to managing them.

METHODS

The study cohort consisted of S-ICD patients who were referred to our institution owing to generator- or lead-related complications requiring surgical intervention. With our "shift and cover" approach, the system component involved is moved from its original position to an alternative, more protected location. In the case of the generator, this involves moving it to an intermuscular pocket. In the case of infections at the parasternal scar, the electrode sleeve is moved away from its original location, stitched, and then covered with the muscular fascia.

RESULTS

Fourteen S-ICD patients were referred to our institution owing to system-related complications. Complications involved the generator in 7 cases (deep pocket infections with erosion, extrusion, or pain), the lead in 5 cases (parasternal infections at the xyphoid incision site), and both the generator and the lead in 2 cases. Complications were managed without completely removing the device and resolved in a single surgical session with no intraoperative complications. During defibrillation testing, the first shock at 65 J was effective in all patients. The shock impedance after revision was significantly lower than that measured during first implantation (59 ± 10 Ohm versus 86 ± 24 Ohm, P = 0.013). In all cases, the cosmetic result was satisfactory. No complications or recurrent infections were reported at the 12-month follow-up visit.

CONCLUSIONS

The proposed conservative approach was successful in managing S-ICD complications. The revision procedure allowed to optimize the system configuration in terms of the defibrillation vector, resulting in lower shock impedance values and better device positioning.

A real‐world experience of subcutaneous and transvenous implantable cardiac defibrillators—comparison with the PRAETORIAN study

Background

Methods

Results

Conclusion

Subcutaneous ICD implantation under ultrasound-guided serratus anterior plane block: Single-center experience in the Netherlands

Introduction

To avoid general anesthesia (GA) and improve postoperative pain management for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation there is a growing interest for alternative methods. We describe the first experience in the Netherlands of S-ICD implantation under Ultrasound-guided Serratus Anterior Plane Block (US-SAPB).

Methods

US-SAPB was performed 1 hour before S-ICD implantation. The two-incision technique was used and a pocket beneath the latissimus dorsi muscle was surgically created. Lidocaine was used to provide anesthesia of the skin. Sedation during defibrillation testing (DFT) was induced by intravenous Propofol. Periprocedural pain experience was monitored using the Numerical Rating Scale for Pain (NRS-Pain). The results were compared with a control group of patients undergoing S-ICD implantation under GA.

Results

Forty consecutive patients (29 Male/11 Female, median age 59 years (range 34–84 years), median body mass index 26 (range 17–41) underwent S-ICD implantation; Twenty patients under US-SAPB and twenty under GA. Median procedure time was 42 min. (range 28–60 min.) with no differences between both groups. In both groups implantations went successful and defibrillation was accomplished using 65 J. US-SAPB was successful in 19 of the 20 patients and GA was successful in all cases. Median NRS-Pain in the US-SAPB group was 2 (range 2–6) and in the GA group 4 (range 2–6). In the US-SAPB group 5 patients required additional opioids postoperatively compared to 10 patients in the GA group.

Conclusions

S-ICD implantation under US-SAPB is feasible, safe and reduces the need for postoperative opioids significantly. S-ICD implantation under US-SAPB seems a good alternative for GA.

Regional Anesthesia in Cardiac Surgery: A Review of the Literature

With our population getting older and sicker, we are witnessing a steady increase in the volume of cardiothoracic procedures performed. As the role of anesthesiologists continues to shift towards being perioperative physicians, it is crucial to tailor the anesthetic to manage the surgical pain in both intraoperative and postoperative periods. In cardiac surgery, poorly controlled surgical pain can lead to opioid-induced hyperalgesia as well as chronic pain syndrome. As current practice encourages early extubation and decreased length of stay, clinicians have increasingly steered away from heavy intraop narcotic therapy over the past two decades. To blunt the sympathetic response and postoperative pain control, some have been using various fascial plane nerve blocks to reduce opioid use during surgery. These blocks are considered very safe to perform and do not lead to hemodynamic changes seen in neuraxial blockades. In this review article, we provide a brief overview of each of the commonly used blocks and summarize and discuss the latest clinical data for each of the common blocks and their efficacy in the setting of cardiothoracic surgery.

Successful implantation of S-ICD using the intermuscular two-incision technique in a patient with severe pectus excavatum

A patient with severe pectus excavatum, dilated ischemic heart disease, and indication for defibrillator implantation for primary prevention of sudden death underwent successful ultrasound-guided serratus anterior plane block and parasternal block with intermuscular two-incision technique implantation with no complications. At follow-up, all the parameters resulted stable with excellent signal sensing.

Adjunctive hypnotic communication for analgosedation in subcutaneous implantable cardioverter defibrillator implantation. A prospective single center pilot study

Background

Subcutaneous implantable cardioverter defibrillator (S-ICD) is a well-established therapy for sudden death prevention. Considering the painful nature of the procedure anaesthesia may be required for analgo-sedation. Hypnosis is emerging as a promising therapeutic strategy for pain control. Few data are available regarding the use of hypnosis as adjunctive technique for pain control during S-ICD implantation.

Methods

Thirty consecutive patients referred to our centre for S-ICD implantation were prospectively and alternatively allocated with 1:1 ratio in two groups: A) Standard analgo-sedation approach (Hypnosis non responder patients) B) Standard analgo-sedation approach with the addition of hypnotic communication (Hypnosis responder patients). Peri-procedural pain perception and anxiety, perceived procedural length, type and dosage of administered analgesic drugs have been measured using validate scores and compared.

Results

Hypnotic communication was offered to 15 patients of which was successful in 11 patients (73%). There were no statistical differences between the two study groups according to baseline characteristics. Hypnosis communication resulted in significant pain perception reduction (Group A 6,9 ± 1,6 Vs Group B 1,1 ± 0,9, p value < 0,01), peri-procedural anxiety (Group A 3,5 ± 1,6 Vs Group B 1,9 ± 0,5, p value < 0,01) and reduced perceived procedural length (Group A 58,7 ± 13,4 min Vs Group B 44,7 ± 5,5 min, p value < 0,01). Fentanyl dosage was significantly lower in Group B patients.

Conclusions

Our results demonstrated a significant reduction of perceived pain, anxiety, procedural time and use of analgesic drugs in hypnosis responder patients. These results reinforce the beneficial effects of the hypnotic technique in patients undergoing S-ICD implantation.

Acute shock efficacy of the subcutaneous implantable cardioverter-defibrillator according to the implantation technique

BACKGROUND

The traditional technique for subcutaneous implantable cardioverter defibrillator (S-ICD) implantation involves three incisions and a subcutaneous (SC) pocket. An intermuscular (IM) 2-incision technique has been recently adopted.

AIMS

We assessed acute defibrillation efficacy (DE) of S-ICD (DE ≤65 J) according to the implantation technique.

METHODS

We analyzed consecutive patients who underwent S-ICD implantation and DE testing at 53 Italian centers. Regression analysis was used to determine the association between DFT and implantation technique.

RESULTS

A total of 805 patients were enrolled. Four groups were assessed: IM + 2 incisions (n = 546), SC + 2 incisions (n = 133), SC + 3 incisions (n = 111), and IM + 3 incisions (n = 15). DE was ≤65 J in 782 (97.1%) patients. Patients with DE ≤65 J showed a trend towards lower body mass index (25.1 vs. 26.5; p = .12), were less frequently on antiarrhythmic drugs (13% vs. 26%; p = .06) and more commonly underwent implantation with the 2-incision technique (85% vs. 70%; p = .04). The IM + 2-incision technique showed the lowest defibrillation failure rate (2.2%) and shock impedance (66 Ohm, interquartile range: 57-77). On multivariate analysis, the 2-incision technique was associated with a lower incidence of shock failure (hazard ratio: 0.305; 95% confidence interval: 0.102-0.907; p = .033). Shock impedance was lower with the IM than with the SC approach (66 vs. 70 Ohm p = .002) and with the 2-incision than the 3-incision technique (67 vs. 72 Ohm; p = .006).

CONCLUSIONS

In a large population of S-ICD patients, we observed a high defibrillation success rate. The IM + 2-incision technique provides lower shock impedance and a higher likelihood of successful defibrillation.

Subcutaneous implantable cardioverter defibrillator in children and adolescents: results from the S-ICD "Monaldi care" registry

BACKGROUND

Implantable cardioverter defibrillators (ICD) are widely accepted therapy in children and adolescents who are survivors of cardiac arrest or for high-risk patients with inheritable channelopathies, cardiomyopathies, or congenital heart disease. Initial experience with subcutaneous ICD (S-ICD) systems has shown a high efficacy in adults. However, the use of S-ICD in children and adolescents implies some specific considerations, as the safety for these patients is unknown and recommendations among physicians may vary widely.

METHODS

We reviewed the data and studied the indications for S-ICD in children and adolescents and discuss the preliminary clinical experience.

RESULTS

From a cohort of 297 patients enrolled in the S-ICD "Monaldi care" registry that encompass all the patients implanted in the Monaldi Hospital of Naples, we considered 21 consecutive children and adolescents (mean age 13.9 years, range 8-18 years, mean body weight 59.3 kg, range 38-100 kg) who underwent S-ICD implant from April 2014 to June 2020. Mean follow-up was 41.9±21.9 months. Only one patient presented, 6 weeks after implantation, skin erosion at the inferior parasternal incision that resolved after antibiotic therapy, without the necessity of any system revision. Two patients experienced appropriate shocks and four inappropriate shocks, due to T wave oversensing or atrial arrhythmia. Only one patient, with arrhythmogenic right ventricular dysplasia, required a system revision after 36 months of the first implantation and then a reintervention with a replacement of the S-ICD by a conventional ICD system.

CONCLUSIONS

Our experience suggests that the S-ICD device can be used in some children over the age of 8 as well as adults, with a similar rate of unwanted side effects, and early evidence of apparent efficacy.

Analgesic Efficacy of Regional Anesthesia of the Hemithorax in Patients Undergoing Subcutaneous Implantable Cardioverter-Defibrillator Placement

OBJECTIVES

Patients undergoing subcutaneous implantable cardioverter-defibrillator (S-ICD) placement usually experience substantial perioperative pain. The aim of the present study was to investigate the effect of transversus thoracic muscle plane block combined with serratus anterior plane block in patients undergoing S-ICD placement.

DESIGN

Double-blind, randomized controlled study.

SETTING

First Affiliated Hospital of Nanchang University.

PARTICIPANTS

Patients aged 18-to-80 years who underwent new S-ICD placement.

INTERVENTIONS

A group of 80 patients randomly were allocated to either the regional group (R group) or local group (L group).

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was pain during S-ICD placement. The secondary outcome measures included pain intensity at rest and after movement one, three, six, 12, 24, and 48 hours after surgery; the dose of dexmedetomidine and remifentanil during surgery; 24-hour ketorolac administration; postoperative sufentanil dosage; the total duration of hospitalization; intraoperative sedation; and the incidence of hypoxemia. Mean Critical-Care Pain Observation Tool scores were significantly higher during pocket creation, lead tunneling A, and lead tunneling B in the L group compared with the R group. The R group required significantly less intraoperative dexmedetomidine, intraoperative remifentanil, postoperative sufentanil, and ketorolac consumption. Compared with the R group, the L group had higher Numerical Rating Scale pain scores at 24 hours after surgery both at rest and after movement. The intraoperative Ramsay score and the incidence of hypoxemia were significantly higher in the L group compared with the R group.

CONCLUSIONS

Ultrasound-guided transversus thoracic muscle plane block and serratus anterior plane block resulted in lower intraoperative Critical-Care Pain Observation Tool scores and the need for less adjunctive pain medication and sedation compared with local anesthesia in patients undergoing S-ICD placement.

Efficacy of Truncal Plane Blocks in Pediatric Patients Undergoing Subcutaneous Implantable Cardioverter-Defibrillator Placement

OBJECTIVES

Pediatric patients undergoing subcutaneous implantable cardioverter-defibrillator (S-ICD) placement usually have substantial postoperative pain. The aim of this study was to investigate the effect of the transversus thoracic muscle plane (TTMP) block combined with serratus anterior plane block (SAPB) in patients undergoing S-ICD placement.

DESIGN

A double-blind, randomized controlled study.

SETTING

First Affiliated Hospital of Nanchang University.

PARTICIPANTS

Patients aged nine-to-18 years undergoing S-ICD placement were included.

INTERVENTIONS

A group of 102 patients randomly were allocated to either receive combined nerve blocks (NER group) or no nerve block (CON group).

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was perioperative fentanyl consumption. The secondary outcome measures included pain at rest and after movement at two, four, six, 12, 24, and 48 hours after extubation; 48-hour acetaminophen administration; time to extubation; length of stay in the postanesthesia care unit (PACU); length of hospital stay; codeine tablet consumption; and percentage of patients who had codeine tablets after discharge. The NER group reported significantly less intraoperative (4.1 μg/kg v 3.1 μg/kg, p = 0.04) and postoperative fentanyl consumption (3.8 μg/kg v 1.5 μg/kg, p = 0.006) than the CON group. Compared with the NER group, the CON group had higher Numerical Rating Scale (NRS) pain scores at 24 hours after surgery both at rest and after movement. The time to extubation (20.5 minutes v 12.6 minutes, p = 0.03) and length of stay in the PACU (30.5 minutes v 15.6 minutes, p = 0.02) were significantly decreased in the NER group compared with the CON group. The CON group had a significantly higher postoperative acetaminophen requirement than did the NER group (32 mg/kg v 16 mg/kg, p = 0.01).

CONCLUSION

TTMP block combined with SAPB in pediatric S-ICD placement could provide effective analgesia.

Implantation technique and optimal subcutaneous defibrillator chest position: a PRAETORIAN score-based study

Aims

The traditional technique for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation involves three incisions and a subcutaneous pocket. Recently, a two-incision and intermuscular (IM) technique has been adopted. The PRAETORIAN score is a chest radiograph-based tool that predicts S-ICD conversion testing. We assessed whether the S-ICD implantation technique affects optimal position of the defibrillation system according to the PRAETORIAN score.

Methods and results

We analysed consecutive patients undergoing S-ICD implantation. The χ2 test and regression analysis were used to determine the association between the PRAETORIAN score and implantation technique. Two hundred and thirteen patients were enrolled. The S-ICD generator was positioned in an IM pocket in 174 patients (81.7%) and the two-incision approach was adopted in 199 (93.4%). According to the PRAETORIAN score, the risk of conversion failure was classified as low in 198 patients (93.0%), intermediate in 13 (6.1%), and high in 2 (0.9%). Patients undergoing the two-incision and IM technique were more likely to have a low (&lt;90) PRAETORIAN score than those undergoing the three-incision and subcutaneous technique (two-incision: 94.0% vs. three-incision: 78.6%; P = 0.004 and IM: 96.0% vs. subcutaneous: 79.5%; P = 0.001). Intermuscular plus two-incision technique was associated with a low-risk PRAETORIAN score (hazard ratio 3.76; 95% confidence interval 1.01–14.02; P = 0.04). Shock impedance was lower in PRAETORIAN low-risk patients than in intermediate-/high-risk categories (66 vs. 96 Ohm; P = 0.001). The PRAETORIAN score did not predict shock failure at 65 J.

Conclusion

In this cohort of S-ICD recipients, combining the two-incision technique and IM generator implantation yielded the lowest PRAETORIAN score values, indicating optimal defibrillation system position.

Clinical trial registration

http://clinicaltrials.gov/ Identifier: NCT02275637.

State-of-the-art consensus on non-transvenous implantable cardioverter-defibrillator therapy

Within the last decade, implantable cardioverter-defibrillator (ICD) systems with non-transvenous leads were developed in order to minimize complications related to the cardiovascular position of transvenous ICD leads. This national expert consensus gives an overview of potential indications for the implantation of non-transvenous ICD systems, and provides specific recommendations for implantation, follow-up, and complication management in patients with subcutaneous ICD. Regarding particular issues like the necessity for shock efficacy testing, or the clinical outcome as compared to transvenous ICD, randomized data are expected in the near future.

Recent Developments in Cardiology Procedures for Adult Congenital Heart Disease: The Anesthesiologist's Perspective

Many children born today with congenital heart disease can expect to live long into adulthood. Improvements in surgical technique and anesthetic and perioperative care have significantly increased the number of survivors. Unfortunately, as these patients progress through life they frequently require further interventions. Although surgical intervention may be required frequently, these patients can be managed in the cardiac catheterization or electrophysiology laboratory. Surgical correction of tetralogy of Fallot can leave patients with pulmonary valve dysfunction later in life. A percutaneous approach is now available for these patients, which can obviate the need for resternotomy. During deployment of the valve, anesthesiologists should be aware that compression of coronary arteries can occur. Adult congenital heart disease (ACHD) patients often require pacemaker/implantable cardioverter- defibrillator (ICD) insertion or ablation therapy. These patients may have altered cardiac anatomy, which can make endovascular procedures extremely challenging. Recent developments have made these procedures safer and more efficient. A number of congenital cardiac conditions can also be associated with orofacial abnormalities. ACHD patients, as a result, can present with challenging airways. The catheterization laboratory may not be the optimum environment for the anesthesiologist to manage a difficult airway. The requirement of transesophageal echocardiography for some cath eterization procedures needs to be considered when deciding on an airway management plan. Knowledge of the underlying cardiac anatomy and the planned procedure is advised when providing anesthesia for this complex patient group outside the theater setting.

Ultrasound-guided serratus anterior plane block combined with parasternal block in subcutaneous implantable cardioverter defibrillator implantation: Results of a pilot study

BACKGROUND

The standard approach to subcutaneous defibrillator (S-ICD) implantation often requires general anesthesia or anesthesiologist-delivered deep sedation. Ultrasound-guided serratus anterior plane block (SAPB) combined with parasternal block (PSB) has been proposed in order to provide anesthesia/analgesia and to reduce the need for sedation during S-ICD implantation. In this pilot study, we compared the double-block approach (SAPB + PSB) with the single-block approach (SAPB only) and with the standard approach involving local anesthesia and sedation.

METHODS

We prospectively enrolled 22 patients undergoing S-ICD implantation: in 10, the single-block approach was adopted; in 12, the double-block approach. As a control group, we retrospectively enrolled 14 consecutive patients who had undergone S-ICD implantation under standard local anesthesia and sedation in the previous 6 months. Intra- and postprocedural data, including patient-reported pain intensity, were collected and compared in the three study groups.

RESULTS

The double-block approach was associated with a shorter procedure duration than the single-block and standard approaches (63.3 ± 7.9 vs 70.1 ± 6.8 vs 76.9 ± 7.8 min; P < .05) and with a lower dose of local an aesthetic for infiltration (18.9 ± 1.7 vs 27.5 ± 4.6 vs 44.6 ± 4.0 cc; P < .001). Both the double- and single-block approaches were associated with lower pain intensity at the device pocket and the lateral tunneling site (P < .05). The double-block approach proved superior to the other two approaches in controlling intraoperative pain at the parasternal tunneling site (P < .05).

CONCLUSIONS

In our study, SAPB combined with PSB was superior to SAPB alone and to the standard approach in controlling intraoperative pain during S-ICD implantation. In addition, this approach resulted in shorter procedure durations.

Left-Sided Humerus Fracture as an Unusual Complication of Defibrillation Threshold Testing Following S-ICD Implantation

Comminuted subcapital humerus fracture as a complication of subcutaneous implantable cardioverter-defibrillator insertion is related to an abducted and externally rotated arm position during the defibrillation threshold test at which the current pathway is through the pectoral muscle. It is advisable to adduct the arm before defibrillation threshold testing. (Level of Difficulty: Beginner.)

Ultrasound-guided serratus anterior plane block for subcutaneous implantable cardioverter defibrillator implantation using the intermuscular two-incision technique

PURPOSE

Operative anaesthetic requirements and perioperative discomfort are barriers to wide adoption of the subcutaneous implantable cardioverter defibrillator (S-ICD) system, especially when the intermuscular technique is used because of the greater amount of tissue dissection. The procedure is most commonly performed under general anaesthesia (GA). There is growing interest in transitioning away from the routine use of GA and towards several alternative anaesthesia modalities for the S-ICD implant procedure without the involvement of an anaesthesiologist. We assessed the feasibility of ultrasound-guided serratus anterior plane block (US-SAPB) in patients undergoing S-ICD implantation with the intermuscular two-incision technique.

METHODS

The study population included 38 consecutive patients (84% male; median, 53 [46-62] years) who received S-ICD implantation using the intermuscular two-incision technique. All procedures were performed under US-SAPB and conscious sedation without the involvement of an anaesthesiologist.

RESULTS

The average procedure time was 67 ± 14 min. No patient experienced significant haemodynamic changes or oxygen desaturation during the period of the US-SAPB procedure and sedation; there was no need for pharmacological interventions. The entire procedure was well tolerated without discomfort or complications and with no need for GA, except in one (2.6%) patient who received GA with a laryngeal mask airway. Patients always remained able to respond appropriately to neurological monitoring during the S-ICD implantation procedure. There were no procedure-related complications.

CONCLUSIONS

US-SAPB and the intermuscular two-incision technique may be a promising safe and feasible combination for S-ICD implantation, overcoming the potential barrier to wider S-ICD adoption in clinical practice.

Feasibility and safety of same day subcutaneous defibrillator implantation and send home (DASH) strategy

PURPOSE

To assess the feasibility and safety of same-day discharge after S-ICD implantation by implementing a specific analgesia protocol and phone follow-up.

METHODS

Consecutive patients presenting for outpatient S-ICD implantation were enrolled between 1/1/2018 and 4/30/2019. An analgesia protocol included pre-operative acetaminophen and oxycodone, intraoperative local bupivacaine, and limited use of oxycodone-acetaminophen at discharge. The primary outcome was successful same-day discharge. Numerical Pain Rating Scale (NPRS) on postoperative day (POD) 1, 3, 14, and 30 and any unplanned health care visits during the 1-month follow-up period were assessed.

RESULTS

Out of 53 potentially eligible S-ICD patients, 49 patients (92.5%) were enrolled and successfully discharged on the same day. Mean age of these 49 patients was 47 ± 14 years. There were no acute procedural complications. Severe pain (NPRS ≥ 8) on POD 0, 1, and 3 was present in 14.3%, 14.3%, and 8.2% of patients, respectively. The total in-hospital stay was 534 ± 80 min. Four unplanned visits (8%) due to cardiac or device-related issues occurred during 1-month follow-up, including 2 patients with heart failure exacerbation, one patient with an incisional infection, and one patient with inappropriate shocks.

CONCLUSIONS

With the appropriate institutional protocol including specific analgesics and phone follow-up, same-day discharge after outpatient S-ICD implantation is feasible and appears safe for most patients.. Device-related pain can be severe in the first 3 days post-implantation and can be successfully treated with limited supply of narcotic medications.

The subcutaneous implantable cardioverter-defibrillator: Current trends in clinical practice between guidelines and technology progress

The subcutaneous implantable cardioverter defibrillator (S-ICD) is a valuable alternative to the conventional trans-venous ICD (TV-ICD) for the prevention of sudden cardiac death (SCD). Prospective registries showed that the S-ICD is safe and effective in treating ventricular tachyarrhythmias in high-risk patients without pacing indications. While in earlier studies patients implanted with S-ICDs were young and mostly affected by channelopathies, contemporary S-ICD cohorts include patients with severely impaired left ventricular function and significant comorbidities. This review focuses on S-ICD evidence-based use and highlights current gaps between guidelines recommendations and real-world clinical practice.

Spotlight on S-ICD™ therapy: 10 years of clinical experience and innovation

Subcutaneous ICD (S-ICD™) therapy has been established in initial clinical trials and current international guideline recommendations for patients without demand for pacing, cardiac resynchronization, or antitachycardia pacing. The promising experience in ‘ideal’ S-ICD™ candidates increasingly encourages physicians to provide the benefits of S-ICD™ therapy to patients in clinical constellations beyond ‘classical’ indications of S-ICD™ therapy, which has led to a broadening of S-ICD™ indications in many centres. However, the decision for S-ICD™ implantation is still not covered by controlled randomized trials but rather relies on patient series or observational studies. Thus, this review intends to give a contemporary update on available empirical evidence data and technical advancements of S-ICD™ technology and sheds a spotlight on S-ICD™ therapy in recently discovered fields of indication beyond ideal preconditions. We discuss the eligibility for S-ICD™ therapy in Brugada syndrome as an example for an adverse and dynamic electrocardiographic pattern that challenges the S-ICD™ sensing and detection algorithms. Besides, the S-ICD™ performance and defibrillation efficacy in conditions of adverse structural remodelling as exemplified for hypertrophic cardiomyopathy is discussed. In addition, we review recent data on potential device interactions between S-ICD™ systems and other implantable cardio-active systems (e.g. pacemakers) including specific recommendations, how these could be prevented. Finally, we evaluate limitations of S-ICD™ therapy in adverse patient constitutions, like distinct obesity, and present contemporary strategies to assure proper S-ICD™ performance in these patients. Overall, the S-ICD™ performance is promising even for many patients, who may not be ‘classical’ candidates for this technology.

Multicentre experience with the second-generation subcutaneous implantable cardioverter defibrillator and the intermuscular two-incision implantation technique

Introduction

The recently developed second‐generation subcutaneous implantable cardioverter defibrillator (S‐ICD) and the intermuscular two‐incision implantation technique demonstrate potential favorable features that reduce inappropriate shocks and complications. However, data concerning large patient populations are lacking. The aim of this multicentre prospective study was to evaluate the safety and outcome of second‐generation S‐ICD using the intermuscular two‐incision technique in a large population study.

Methods and Results

The study population included 101 consecutive patients (75% male; mean age, 45 ± 13 years) who received second‐generation S‐ICD (EMBLEM; Boston Scientific, Marlborough, MA) implantation using the intermuscular two‐incision technique as an alternative to the standard implantation technique. Twenty nine (29%) patients were implanted for secondary prevention. Twenty four (24%) patients had a previously implanted transvenous ICD. All patients were implanted without any procedure‐related complications. Defibrillation testing was performed in 80 (79%) patients, and ventricular tachycardia was successfully converted at less than or equal to 65 J in 98.75% (79/80) of patients without pulse generator adjustments. During a median follow‐up of 21 ± 10 months, no complications requiring surgical revision or local or systemic device‐related infections were observed. Ten patients (9.9%) received appropriate and successful shocks for ventricular arrhythmias. Three (2.9%) patients experienced inappropriate shocks due to oversensing the cardiac signal (n = 1), noncardiac signal (n = 1), and a combination of both cardiac and noncardiac signals (n = 1), with one patient requiring device explantation. No patients required device explantation due to antitachycardia pacing indications.

Conclusions

According to our multicentre study, second‐generation S‐ICD implanted with the intermuscular two‐incision technique is an available safe combination and appears to be associated with a low risk of complications, such as inappropriate shocks.

Impact of the Ultrasound-Guided Serratus Anterior Plane Block on Post-Mastectomy Pain: A Randomised Clinical Study

Objective

A variety of methods, including neuraxial and regional blocks, have been used to manage post-mastectomy pain. This study evaluates the effect of serratus anterior plane block on acute pain after mastectomy.

Methods

A total of 60 patients who were candidates for mastectomy under general anaesthesia were divided in this trial into two groups. After entering the recovery room, the first-experimental-group (SAB) underwent the ultrasound-guided serratus anterior block, but the second-control-group (CTL) received no block intervention. An intravenous patient-controlled analgesia (PCA) device was used to deliver fentanyl in both groups. Using the Visual Analog Scale (VAS), the patients' pain was assessed at intervals of 1, 6, 12 and 24 hours after entering the recovery room. Intravenous acetaminophen was administered as a rescue analgesic if the pain exceeded 3 on the VAS. A total amount of fentanyl consumed, the time to first PCA request, a total amount of acetaminophen consumption and possible adverse effects were evaluated.

Results

The pain scores assessed at the time intervals were not significantly different between the two groups (p>0.5). The total consumption of fentanyl was significantly lower in the SAB group than in the CTL group (p=0.0001). Duration of the time to first PCA request was remarkably longer in the SAB group than in the CTL group (p=0.0001). The total amount of acetaminophen consumed was notably higher in the CTL group than in the SAB group (p=0.001). None of the patients experienced side effects.

Conclusion

Undertaking serratus anterior block following mastectomy can reduce pain scores and lower opioid usage.

An Overview of Clinical Outcomes in Transvenous and Subcutaneous ICD Patients

PURPOSE OF REVIEW

Clear guidelines on when to select a subcutaneous ICD (S-ICD) over a transvenous ICD (TV-ICD) are lacking. This review will provide an overview of the most recent clinical data on S-ICD and TV-ICD therapy by pooling comparison studies in order to aid clinical decision making.

RECENT FINDINGS

Pooling of observational-matched studies demonstrated an incidence rate ratio (IRR) for device-related complication of 0.90 (95% CI 0.58-1.42) and IRR for lead-related complications of 0.15 (95% CI 0.06-0.39) in favor of S-ICD. The IRR for device infections was 2.00 (95% CI 0.95-4.22) in favor of TV-ICD. Both appropriate shocks (IRR 0.67 (95% CI 0.42-1.06)) and inappropriate shocks (IRR 1.17 (95% CI 0.77-1.79)) did not differ significantly between both groups. With randomized data underway, the observational data demonstrate that the S-ICD is associated with reduced lead complications, but this has not yet resulted in a significant reduction in total number of complications compared to TV-ICDs. New technologies are expected to make the S-ICD a more attractive alternative.