title: Subxiphoid approach to epicardial implantation of implantable cardioverter defibrillators in children.
abstract: BACKGROUND
  Epicardial implantation of implantable cardioverter defibrillators (ICDs) is considered in the presence of intracardiac shunt, venous access issue, or small body size. We report our experience with epicardial ICD coil implantation using a minimally invasive method.
  
  
  METHODS
  Nine patients who underwent epicardial ICD implantation were included. The median age was 7.4 years (3.9-9.6 years) and the median weight was 15 kg (12-24 kg). Diagnosis at the time of implantation included long QT syndrome (n = 5), catecholaminergic polymorphic ventricular tachycardia (n = 2), hypertrophic cardiomyopathy (n = 1), and fast monomorphic ventricular tachycardia (n = 1). The minimally invasive method involved a subxiphoid incision to place the epicardial pacing leads. The ICD coil was placed in the transverse sinus in four patients using an access path posterior to the heart. The second approach involved a path anterior to the heart to reach the epicardial location posterior to the left atrial appendage in the five remaining patients. No fluoroscopy was used in either approach. The median defibrillation threshold (DFT) at implantation was 7.5 J.
  
  
  RESULTS
  Lower DFTs were observed in the anterior approach (10 J vs 5 J). Appropriate ICD shocks were observed in three patients during the median 18-month follow-up period (0.3-28 months). No inappropriate shocks were noted. One patient developed pericardial tamponade 39 days after the procedure and was surgically drained.
  
  
  CONCLUSIONS
  Minimally invasive epicardial ICD coil implantation in children with low DFT values is possible. The anterior implantation approach appears superior to the posterior approach.
authors.affiliation: Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey. sehaydin@hotmail.com
authors.forename: Sertac
authors.initials: S
authors.lastname: Haydin
authors.forename: Murat
authors.initials: M
authors.lastname: Saygi
authors.forename: Yakup
authors.initials: Y
authors.lastname: Ergul
authors.forename: Isa
authors.initials: I
authors.lastname: Ozyilmaz
authors.forename: Erkut
authors.initials: E
authors.lastname: Ozturk
authors.forename: Celal
authors.initials: C
authors.lastname: Akdeniz
authors.forename: Volkan
authors.initials: V
authors.lastname: Tuzcu
mesh_terms: D002356:Cartilage / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D017147:Defibrillators, Implantable; D004567:Electrodes, Implanted; D005260:Female; D006333:Heart Failure / Q000517:prevention & control* / Q000601:surgery; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D010496:Pericardium / Q000601:surgery*; D019919:Prosthesis Implantation / Q000379:methods; D056346:Sternotomy / Q000379:methods*
keywords: implantable cardioverter defibrillator; pediatrics; subxiphoid; surgery