Nontraditional implantable cardioverter defibrillator placement in adult patients with limited venous access: a case series.
BACKGROUND
Conventional transvenous approaches for implantable cardioverter defibrillator (ICD) lead placement are not possible in some patients with limited venous access or severe tricuspid valve dysfunction.


METHODS
We retrospectively identified six patients who underwent ICD placement or revision requiring nontraditional alternative surgical lead placement at our institution between November 2006 and August 2008. The baseline and operative patient characteristic data were accumulated and reviewed.


RESULTS
All the patients (mean age 71 +/- 3.4 years) underwent nontraditional surgical placement of epicardial ICD leads and traditional placement of ventricular epicardial bipolar pacing/sensing leads. Five patients had the distal lead tip fixed to the anterior epicardium of the right ventricular outflow tract, which was then looped under and around the ventricles, forming a "sling," and tunneled to a left subclavicular pocket. One patient had a single unipolar subcutaneous array lead fashioned into a "loop" and placed under the inferior aspect of the ventricles. The average procedure time was 311 +/- 115 minutes with a mean defibrillatory threshold (DFT) of < or = 22 + 3 J. Post-procedure hospitalization was 9.3 +/- 4.4 days and no device-related complications were encountered. Mean device follow-up of 451 + 330 days showed normal function and two appropriate successful ICD discharges.


CONCLUSIONS
Nontraditional alternative surgical methods for the placement of ICD systems in adult patients with limited venous access or TV dysfunction can achieve results similar to those of conventionally placed endovascular leads with limited complications and comparable DFTs in short-term follow-up.
Division of Cardiovascular Diseases, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
Mayurkumar
M
Bhakta
Chedozie C
CC
Obioha
Dan
D
Sorajja
Komadoor
K
Srivathsan
Francisco A
FA
Arabia
Patrick A
PA
Devaleria
Dawn E
DE
Jaroszewski
Luis R
LR
Scott
Gregory T
GT
Altemose
D000368:Aged; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000379:methods*; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D004567:Electrodes, Implanted; D005260:Female; D006331:Heart Diseases / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008297:Male; D019919:Prosthesis Implantation / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014680:Veins / Q000601:surgery