Thorac Cardiovasc Surg 2020; 68(S 02): S79-S101
DOI: 10.1055/s-0040-1705578
Short Presentations
Monday, March 2nd, 2020
CHD Surgery
Georg Thieme Verlag KG Stuttgart · New York

S-ICD in Congenital Heart Disease —How to Implant a Simple System into a Complex Anatomy

L. Ghaeni
1   Berlin, Germany
,
F. Danne
1   Berlin, Germany
,
M. Yigitbasi
1   Berlin, Germany
,
F. Groß
1   Berlin, Germany
,
F. Berger
1   Berlin, Germany
,
B. Peters
1   Berlin, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
13 February 2020 (online)

Objectives: The subcutaneous implantable cardioverter-defibrillator (S-ICD) provides a therapy option for patients with congenital heart disease (CHD), even when conventional ICD therapy is impossible due to complex anatomy, without necessity of thoracotomy or vascular access.

Methods: We treated a very heterogeneous group of 22 patients with CHD since 2011. Reasons to opt in for S-ICD were accordingly complex. Some were very young (minimum, 8 years, 28 kg), facing long-term therapy, without pacing indication. The majority presented with challenging features: Missing vascular access (e.g., univentricle with Glenn’s anastomosis), tricuspid valve dysplasia, ventricular assist device (VAD), or chronic right-to-left shunt. S-ICD was also combined with epicardial pacing. Lead and device positioning were modified according to anatomic variations, such as dextrocardia. The two first implantations were subcutaneous, afterwards inter- or submuscular. Three-incision technique was optimized to two-incisions.

Result: All implantations were successful, over three-device generations since 2011 with follow-up. We had a significant learning curve. Even in smallest patients inter-/submuscular placement with two-incisions had excellent cosmetic results and clinical tolerance, without migration despite relevant somatic growth. Patients with events received appropriate therapy. However, some received inappropriate shocks, mostly from t-wave oversensing (TWOS) under higher heart rate. Interestingly, few patients received “pseudoappropriate” shocks (episodes that were misinterpreted by device thus treated with clinical benefit). A patient with severe scoliosis received inappropriate shocks due to low amplitude in certain body positions. Combination of S-ICD and epicardial pacing was feasible, although in one case false unipolar programming led to inappropriate therapy. Overall, by firmware updating and modified programming adapted over the time, we could successfully address and reduce inappropriate shocks. Two patients had to be switched to transvenous systems: one suffered from slow VTs and chronotropic incompetence, another with subcutaneous implantation and progressive obesity had late device migration. The patient with VAD died of unknown reason.

Conclusion: S-ICD is a promising future therapy in complex CHD. It allows proper function with good cosmetic results even in distorted anatomy, if protective implantation techniques are applied. A thorough preimplantation screening, modifications in lead device placement, and adapted programming strategies are indispensable. However, the current device generation still precludes its use below approximately 30 kg and lacks antibradycardia and antitachycardia pacing.