655Safety and efficacy of the subpleural ICD lead placement in pediatric patients - long-term follow-up data

Abstract

Efficacy of implantable cardioverter defibrillators (ICD) has already been well established in children. However, the proper choice of implantation system, the lead placement method and appropriate configuration of the device are still challenging and have a major impact on morbidity and quality of life in young ICD recipients. As an alternative to the epicardial approach we used method of subpleural lead placement. Subpleural ICD lead implantation was performed by the left antero-lateral thoracotomy in 5th or 6th intercostal space. Pericardial sac was opened parallelly to the phrenic nerve and the pacing lead was sutured to the left ventricle wall. Defibrillating coil was located under the pleura along the antero-costal space. The ICD generator was placed between the phrenic muscle and the peritoneum. From 2004 to 2016 the method was used in our department in 15 children (pts). The mean pts age at the implantation was 6,6 years (5 wks-17,9 yrs), mean weight 22 kg (4 - 57kg). The reason for the ICD implantation was: the aborted SCD in 14 and primary prevention in 1 pt. The underlying pathologies: LQTS - 10 pts, SQTS - 1 pt, HCM - 2 pts, idiopathic VF - 2 pts. One child underwent prior explantation of endocardial ICD because of infective endocarditis, in 2 pts epicardial pacing system was upgraded to ICD. Technic-related implant complications occurring in 3 pts (1 recurrent pleural effusion required drainage, 1 tension pneumothorax required positive-pressure ventilation, 1 subcutaneous emphysema). During the follow-up period ranging from 3 months to 12,3 yrs (mean 6,54 yrs) 10 pts were reoperated: 2 pts required surgical revision because of lead problems (1 pt - damage, in 1 pt ventricular sensing problems) in 1 girl ICD system was completely removed after successful ablation therapy, 7 devices were replaced due to battery depletion after 3,5 years (4 wks - 5,2 years). Six children received appropriate ICD therapies, in 2 of them antitachycardia pacing was successful. We noticed only 2 inappropriate interventions of ICDs, caused by T Wave Oversensing in 1 case and Pacemaker-Mediated Tachycardia in 1 case. One boy with extremely long QT/QTc interval and frequently recurrent of life-threatening ventricular tachyarrhythmia non responsive to any of antiarrhythmic medication, after bilateral cardiac sympatectomy, died during electrical storm, 3 years 4 months post ICD implantation, his device was three times exchanged because of battery depletion. Conclusions: The subpleural ICD lead implantation seems to be the safe and effective alternative for the epicardial approach in young patients.