Innovative techniques for placement of implantable cardioverter-defibrillator leads in patients with limited venous access to the heart.
BACKGROUND
Because of venous occlusion, intracardiac shunting, previous surgery, or small size placement of implantable cardioverter-defibrillator (ICD) leads may not be possible using traditional methods. The purpose of this study was to evaluate and describe innovative methods of placing ICD leads.


METHODS
The records of all patients undergoing ICD implantation at our institution were reviewed to identify patients with nontraditional lead placement. Indications for ICD, method of lead and coil placement, defibrillation thresholds, complications, and follow-up results were reviewed retrospectively.


RESULTS
Eight patients (aged 11 months to 29 years) were identified. Six patients with limited venous access to the heart (four extracardiac Fontan, one bidirectional Glenn, one 8 kg 11-month-old) underwent surgical placement of an ICD coil directly into the pericardial sac. A second bipolar lead was placed on the ventricle for sensing and pacing. Two patients with difficult venous access had a standard transvenous ICD lead inserted directly into the right atrium (transatrial approach) and then positioned into the ventricle. All patients had a defibrillation threshold of <20 J, although one patient required placement of a second coil due to an elevated threshold. There have been no complications and two successful appropriate ICD discharges at follow-up (median 22 months, range 5-42 months).


CONCLUSIONS
Many factors may prohibit transvenous ICD lead placement. Nontraditional surgical placement of subcutaneous ICD leads on the pericardium or the use of a transatrial approach can be effective techniques in these patients. These procedures can be performed at low risk to the patient with excellent defibrillation thresholds.
Division of Pediatrics, Section of Cardiology, Baylor College of Medicine, Texas Childrens Hospital, Houston, Texas, USA. bcannon@bcm.tmc.edu
Bryan C
BC
Cannon
Richard A
RA
Friedman
Arnold L
AL
Fenrich
Charles D
CD
Fraser
E Dean
ED
McKenzie
Naomi J
NJ
Kertesz
D000293:Adolescent; D000328:Adult; D006328:Cardiac Catheterization / Q000379:methods*; D003251:Constriction, Pathologic; D003330:Coronary Vessel Anomalies; D017147:Defibrillators, Implantable; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D013350:Subclavian Vein; D013908:Thoracotomy / Q000379:methods; D016896:Treatment Outcome; D014683:Vena Cava, Superior