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Minimally invasive epicardial defibrillator or biventricular pacemaker implantation
Session 45 Background: Pacing is a well accepted therapy for patients (pts) with congenital complete AV block (CCAVB). The long term sequelae of right ventricular pacing in this population is not well known. Purpose: The purpose of this study was to determine the effects of long term RV pacing on cardiac function in pts with CCAVB. Methods: We performed a retrospective review of all pts with CCAVB who underwent pacemaker (PM) implantation at our institution from 19722003. Pts with associated congenital heart disease, ventricular dysfunction prior to PM implantation, or no echocardiographic follow-up were excluded. Results: A total of 62 pts were included in the study. The median age at PM implantation was 6.4 ⫹/- 5.4 yrs with an average follow up of 9.8 yrs (0.2-26.7 yrs). Four pts were noted to develop LV dysfunction. One was not included in subsequent analysis as he developed dysfunction only after resuscitated sudden cardiac death due to PM end of life.
The remaining 58 pts (28 epicardial / 30 transvenous) did not develop LV dysfunction. Thirty-one pts were paced for ⬎ 10 yrs. Of them, only 2 (6%) developed echocardiographic evidence of LV dysfunction. All pts with LV dysfunction showed improvement on medical therapy. Conclusions: Left ventricular dysfunction in pts with CCAVB is a rare finding even in those who have been paced for greater than 10 years. Ongoing analysis is recommended to determine which pts are predisposed to developing ventricular dysfunction, and to determine when and if alternative pacing modalities are warranted. At this time, with such a low incidence of cardiac dysfunction, right ventricular pacing should remain the first line therapy in this population.
S89 follow-up, (median: 1 month) 1 pt had an appropriate ICD shock, and there were no inappropriate shocks or lead failures. Conclusion: Epicardial ICD and biventricular pacemaker implantation can be achieved in a minimally invasive fashion even in the smallest and most complex pts. These techniques provide an alternative to sternotomy, thoracotomy and pure subcutaneous coil ICD systems. AB44-6 IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR IN YOUNG PATIENTS WITH ARVC/D- ARE THERE DIFFERENCES IN R WAVE SENSING AMPLITUDE COMPARED WITH PATIENTS WITH OTHER DISEASES? Gabriele Bronzetti, MD, Christine C. Chiu-Man, BSc, *Joel A. Kirsh, MD, FRCP, Elizabeth A. Stephenson, MD, Gil J. Gross, MD, Andrea L. Neilson and Robert M. Hamilton, MD, FRCP. Hospital for Sick Children, Toronto, Ontario, Canada. Introduction: Adult patients with arrhythmogenic right ventricular cadiomyopathy/dysplasia (ARVC/D) are known to have a lower R-wave amplitude compared with other diseases. This may be secondary to fibrofatty replacement of myocardium at the site of RV lead implantation. We sought to compare R wave sensing values and defibrillation thresholds (DFT) in a group of ARVC/D children to a group of children receiving defibrillators for other diseases. Methods: A total of 48 ICD patients were retrospectively studied, 9 with ARVC/D, 39 with other diseases [16 hypertrophic cardiomyopathy (HCM), 3 dilated cardiomyopathy (DCM), 5 complex congenital heart disease (CHD), 2 catecholaminergic polymorphic ventricular tachycardia (CPVT), 5 long QT syndrome (LQTS) and 8 others conditions]. Clinical characteristics assessed included age, number of sites tested , acute sensing and sensing at the follow up. In comparison with the adult patients in the literature our ARVC/D patients were at an early stage of disease. Right ventricular function was preserved in all but one patient and that patient had only mild dysfunction; one patient also had mild LV dysfunction.
AB44-5 MINIMALLY INVASIVE EPICARDIAL DEFIBRILLATOR OR BIVENTRICULAR PACEMAKER IMPLANTATION Frank Cecchin, MD, Frank A. Pigula, MD, Bassem N. Mora, MD, Pedro J. Del Nido, MD and Charles I. Berul, MD. Children’s Hospital Boston, Boston, MA. Epicardial placement can be only lead option for certain pts. These same pts are often the sickest or smallest and would benefit from the least invasive surgical techniques possible. Our aim was to develop minimally invasive implantation methods for those pts needing epicardial (ICD or BiV pacemaker) implants. The technique consists of a single small incision used for both lead and device placement with or without video assisted thorascopic surgery (VATS). From July 2004, minimally invasive implantation was performed on 6 pts, median age 2.4 yrs (5 mths - 43 yrs). ICD’s were implanted in 4 (including 2 infants ⬍ 8 mths of age) and BiV pacemaker’s in 2. Indication for epicardial implant was small body size in 4, inadequate venous access in 1 and large right to left shunt in 1 pt. In the 4 ICD pts an active fixation transvenous ICD lead was advanced blindly into the posterior pericardial space and fixed to the pericardium. Adequate position was then confirmed radiographically prior to DFT testing. A separate bipolar pace/sense lead was placed epicardially. In 3 pts this was done transxiphoid and in 1 pt with a prior transverse subcostal incison the entire dual chamber system was implanted via VATS. The one adult pt had massive cardiac enlargement and required a supplemental anterior subcutaneous coil to provide adequate DFT. Both BIV pacemaker pts were infants with severe dilated cardiomyopathy. Via a transxiphoid approach, suture-on bipolar leads were placed on the right atrium and RVOT. A unipolar lead was placed via VATS on the posterior aspect of the left ventricle. The median hospital stay was 5 days (range 2 - 7 days). Complications included a pleural effusion requiring thoracentesis and a sternal wound infection needing debridement and antibiotics. Over short-term
Result: There was no significant difference in age or defibrillation threshold (DFT) between patients with or without ARVC/D at time of ICD implant. There was a significantly diminished R wave amplitude at time of ICD implant in ARVC/D patients. A trend to lower R wave amplitude in ARVC/D persisted in followup, but did not achieve statistical significance. Conclusion: In ARVC/D patients with ICDs, low R wave sensing is present at implant, and may be related to the fibro-fatty replacement of the myocardium, even in a young population of implanted ARVC/D patients at the early stage of the disease.
ABSTRACT SESSION 45: CATHETER ABLATION VII: Experimental Studies and Surgical Therapy Friday, May 6, 2005 4:45 p.m.– 6:15 p.m. AB45-1 PRE-CLINICAL CANINE TESTING OF ENDOSCOPY TO GUIDE LASER APPLICATIONS FOR PULMONARY VEIN ISOLATION *Hiroshi Nakagawa, MD, PhD, Katsuaki Yokoyama, MD, PhD, Jan V. Pitha, MD, PhD, Samuel J. Asirvatham, MD, Ralph Lazzara, MD and *Warren M. Jackman, MD. Mayo Clinic, St. Marys Hospital, Rochester, MN and Cardiac Arrhythmia Research Institute, University of Oklahoma, Oklahoma City, OK. For laser ablation, laser energy should not be applied through blood, since it is absorbed by blood, reducing lesion size and the potential risk of
The remaining 58 pts (28 epicardial / 30 transvenous) did not develop LV dysfunction. Thirty-one pts were paced for ⬎ 10 yrs. Of them, only 2 (6%) developed echocardiographic evidence of LV dysfunction. All pts with LV dysfunction showed improvement on medical therapy. Conclusions: Left ventricular dysfunction in pts with CCAVB is a rare finding even in those who have been paced for greater than 10 years. Ongoing analysis is recommended to determine which pts are predisposed to developing ventricular dysfunction, and to determine when and if alternative pacing modalities are warranted. At this time, with such a low incidence of cardiac dysfunction, right ventricular pacing should remain the first line therapy in this population.
S89 follow-up, (median: 1 month) 1 pt had an appropriate ICD shock, and there were no inappropriate shocks or lead failures. Conclusion: Epicardial ICD and biventricular pacemaker implantation can be achieved in a minimally invasive fashion even in the smallest and most complex pts. These techniques provide an alternative to sternotomy, thoracotomy and pure subcutaneous coil ICD systems. AB44-6 IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR IN YOUNG PATIENTS WITH ARVC/D- ARE THERE DIFFERENCES IN R WAVE SENSING AMPLITUDE COMPARED WITH PATIENTS WITH OTHER DISEASES? Gabriele Bronzetti, MD, Christine C. Chiu-Man, BSc, *Joel A. Kirsh, MD, FRCP, Elizabeth A. Stephenson, MD, Gil J. Gross, MD, Andrea L. Neilson and Robert M. Hamilton, MD, FRCP. Hospital for Sick Children, Toronto, Ontario, Canada. Introduction: Adult patients with arrhythmogenic right ventricular cadiomyopathy/dysplasia (ARVC/D) are known to have a lower R-wave amplitude compared with other diseases. This may be secondary to fibrofatty replacement of myocardium at the site of RV lead implantation. We sought to compare R wave sensing values and defibrillation thresholds (DFT) in a group of ARVC/D children to a group of children receiving defibrillators for other diseases. Methods: A total of 48 ICD patients were retrospectively studied, 9 with ARVC/D, 39 with other diseases [16 hypertrophic cardiomyopathy (HCM), 3 dilated cardiomyopathy (DCM), 5 complex congenital heart disease (CHD), 2 catecholaminergic polymorphic ventricular tachycardia (CPVT), 5 long QT syndrome (LQTS) and 8 others conditions]. Clinical characteristics assessed included age, number of sites tested , acute sensing and sensing at the follow up. In comparison with the adult patients in the literature our ARVC/D patients were at an early stage of disease. Right ventricular function was preserved in all but one patient and that patient had only mild dysfunction; one patient also had mild LV dysfunction.
AB44-5 MINIMALLY INVASIVE EPICARDIAL DEFIBRILLATOR OR BIVENTRICULAR PACEMAKER IMPLANTATION Frank Cecchin, MD, Frank A. Pigula, MD, Bassem N. Mora, MD, Pedro J. Del Nido, MD and Charles I. Berul, MD. Children’s Hospital Boston, Boston, MA. Epicardial placement can be only lead option for certain pts. These same pts are often the sickest or smallest and would benefit from the least invasive surgical techniques possible. Our aim was to develop minimally invasive implantation methods for those pts needing epicardial (ICD or BiV pacemaker) implants. The technique consists of a single small incision used for both lead and device placement with or without video assisted thorascopic surgery (VATS). From July 2004, minimally invasive implantation was performed on 6 pts, median age 2.4 yrs (5 mths - 43 yrs). ICD’s were implanted in 4 (including 2 infants ⬍ 8 mths of age) and BiV pacemaker’s in 2. Indication for epicardial implant was small body size in 4, inadequate venous access in 1 and large right to left shunt in 1 pt. In the 4 ICD pts an active fixation transvenous ICD lead was advanced blindly into the posterior pericardial space and fixed to the pericardium. Adequate position was then confirmed radiographically prior to DFT testing. A separate bipolar pace/sense lead was placed epicardially. In 3 pts this was done transxiphoid and in 1 pt with a prior transverse subcostal incison the entire dual chamber system was implanted via VATS. The one adult pt had massive cardiac enlargement and required a supplemental anterior subcutaneous coil to provide adequate DFT. Both BIV pacemaker pts were infants with severe dilated cardiomyopathy. Via a transxiphoid approach, suture-on bipolar leads were placed on the right atrium and RVOT. A unipolar lead was placed via VATS on the posterior aspect of the left ventricle. The median hospital stay was 5 days (range 2 - 7 days). Complications included a pleural effusion requiring thoracentesis and a sternal wound infection needing debridement and antibiotics. Over short-term
Result: There was no significant difference in age or defibrillation threshold (DFT) between patients with or without ARVC/D at time of ICD implant. There was a significantly diminished R wave amplitude at time of ICD implant in ARVC/D patients. A trend to lower R wave amplitude in ARVC/D persisted in followup, but did not achieve statistical significance. Conclusion: In ARVC/D patients with ICDs, low R wave sensing is present at implant, and may be related to the fibro-fatty replacement of the myocardium, even in a young population of implanted ARVC/D patients at the early stage of the disease.
ABSTRACT SESSION 45: CATHETER ABLATION VII: Experimental Studies and Surgical Therapy Friday, May 6, 2005 4:45 p.m.– 6:15 p.m. AB45-1 PRE-CLINICAL CANINE TESTING OF ENDOSCOPY TO GUIDE LASER APPLICATIONS FOR PULMONARY VEIN ISOLATION *Hiroshi Nakagawa, MD, PhD, Katsuaki Yokoyama, MD, PhD, Jan V. Pitha, MD, PhD, Samuel J. Asirvatham, MD, Ralph Lazzara, MD and *Warren M. Jackman, MD. Mayo Clinic, St. Marys Hospital, Rochester, MN and Cardiac Arrhythmia Research Institute, University of Oklahoma, Oklahoma City, OK. For laser ablation, laser energy should not be applied through blood, since it is absorbed by blood, reducing lesion size and the potential risk of