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Background Implantable cardioverter defibrillators (ICDs) are intended to prevent sudden cardiac death yet also impose a risk of morbidity. This study describes the outcomes of ICDs in a pediatric and congenital heart disease (CHD) population from a single center. Methods Retrospective cohort study of all patients with an ICD followed at the University of Michigan Congenital Heart Center from 2005-2013. The primary outcome was ICD system revision for any reason excluding routine generator change for battery depletion. Results There were 191 ICD systems in 131 patients, including 57 with CHD, 24 with hypertrophic cardiomyopathy, and 45 with structurally normal hearts. Median age was 16 years at initial implant. Total follow-up was 850 patient-years; median 4.9 years/patient. There were 43 (33%) patients who required 60 ICD revisions; 70 revisions/1,000 patient-years of follow-up. Revisions included 25 lead extractions with replacement, 21 lead additions, five lead repositions, and four full system revisions. Kaplan-Meier (K-M) median time to appropriate shock was similar to the median time to system revision. K-M time to system revision was significantly affected by recalled lead performance. Conclusions The need for ICD system revision is high in this pediatric and CHD population and occurs at a rate similar to the rate of receiving appropriate therapy. These results highlight the need for judicious implant criteria and improved device longevity. [ABSTRACT FROM AUTHOR]

Background: Implantable cardioverter defibrillator (ICD) use is increasing in young patients and is frequently complicated by inappropriate device discharges (IDs), leading to discomfort, anxiety and, potentially, proarrhythmia. Dual-chamber (DC) ICDs may decrease IDs by improving rhythm discrimination, but are associated with increased size, expense, and implant complications. We examined whether the frequency of IDs was the same in dual- and single-chamber (SC) ICDs in young patients. Methods: A multicenter review of patients ≤30 years of age with ICDs was performed. Demographic data and number of appropriate discharges (ADs) and IDs were collected. ADs and IDs were categorized after review of the episode by the primary electrophysiologist. Results: Of 168 subjects (SC = 52; female = 76), 41 patients received 139 ADs, while 35 patients received 159 IDs. There were no differences related to gender or primary diagnosis, but patients with SC versus DC devices were younger (12.3 ± 5.0 years vs 14.9 ± 4.4 years, P < 0.0001) at implant. SC and DC devices were implanted with the same frequency for primary and secondary prevention. There were no significant differences in the incidence of IDs or ADs between the patients with SC or DC devices (AD: 12/52 SC vs 29/116 DC, P = 0.79; ID 7/52 SC vs 28/116 DC, P = 0.13). Conclusion: In this cohort of young patients, DC ICDs did not provide added protection from IDs. Hence, the added complexity and cost of an atrial lead appear unwarranted if used solely for assistance with rhythm discrimination in young patients. [ABSTRACT FROM AUTHOR]

While transvenous defibrillator electrode placement avoiding a thoracotomy is preferable, electrode size, a large intercoil spacing, and the need for subclavicular device placement preclude this approach in most children. We investigated a single RV coil to an abdominally placed active can ICD device. Five children ages 8-16 years (weight 21-50 kg, mean 35 kg) underwent ICD placement. Placement of a single coil Medtronic model 6932 or 6943 electrode was performed via the left subclavian vein approach and the electrode positioned in the HV apex with the coil lying along the RV diaphragmatic surface. The ICD (Medtronic Micro Jewel II model 7223Cx) was implanted in a left abdominal pocket with the lead tunneled from the infraclavicular region to the pocket. Implant DFTs were ⩽15 J using a biphasic waveform. DFTs rechecked within 3-month postimplant were unchanged. Lead impedance at implant ranged from 38 to 56 Ω, mean 51 Ω. Follow-up was 3-21 months (total 82 months) with no electrode dislodgment. lead fractures, or inappropriate discharges. Two of the five patients have had successful appropriate ICD discharges. Transvenous ICD electrode placement can be performed in children as small as 20 kg with the device implanted in a cosmetically acceptable abdominal pocket that is well tolerated. Excellent DFTs can be achieved. This approach avoids a thoracotomy in all hut the smallest child, does not require subclavicular placement of the device, and avoids use of a second intravascular coil. [ABSTRACT FROM AUTHOR]

Use of IV (Conscious) Sedation/Analgesia by Nonanesthesia Personnel in Patients Undergoing Arrhythmia Specific Diagnostic, Therapeutic, and Surgical Procedures. This article is intended to inform practitioners, payers, and other interested parties of the opinion of the North American Society of Pacing and Electrophysiology (NASPE) concerning evolving areas of clinical practice or technologies or both, that are widely available or are new to the practice community. Expert consensus documents are so designated because the evidence base and experience with the technology or clinical practice are not yet sufficiently well developed, or rigorously controlled trials are not yet available that would support a more definitive statement. This article has been endorsed by the American College of Cardiology, October 1997. [ABSTRACT FROM AUTHOR]

Percutaneous catheter mapping and radiofrequency ablation of the AV node-His bundle system (with subsequent transvenous endocardial ventricular pacing) were performed on an 18-year-old woman with transposition of the great arteries and intact ventricular septum and chronic arrhythmias 15 years following a Mustard operation. Exclusion of the AV conduction tissue from the systemic venous circulation by the complex anatomy and the Mustard repair was circumvented by a retrograde approach across the aortic valve to the morphological right ventricle yielding access to the AV node-His bundle system. [ABSTRACT FROM AUTHOR]

Intraoperative mapping and radiofrequency ablation of the His bundle (with epicardial ventricular pacing) were performed in an 18-year-old woman with complex congenital heart disease and intractable chronic atrial arrhythmias following the Fortran operation. The presence of complex intracardiac anatomy as well as the exclusion of the atrioventricular conduction tissue from the systemic venous circulation strongly influenced the technical approach. [ABSTRACT FROM AUTHOR]

Supraventricular tachycardia (SVT), the most common sustained symptomatic arrhythmia of childhood, is often supported by a manifest or concealed accessory pathway. Permanent interruption of the accessory path- way usually requires surgical division. Recent experience with electrical ablation of posterior septal pathways in adults prompted us to apply the technique to children. Six children, ages 8 to 15 years, underwent a complete electrophysiological study followed by transcatheter electrical ablation. Five of the 6 children, 3 with a right posterior septal and 2 with a left posterior septal pathway, were approached with the ablation catheter at the os of the coronary sinus. In the remaining patient, a left lateral pathway was mapped with an electrode catheter in the coronary sinus and then approached with the ablation catheter through the patent foramen into the left atrium. Two patients are asymptomatic 18-24 months postablation; one patient had return of anomalous conduction between 7 and 21 days after ablation. Two patients had transient interruption of anomalous conduction, whereas one patient experienced no effect. We conclude that in carefully selected patients, transcatheter electrical ablation offers an alternative to surgery for permanent interruption of an accessory pathway. [ABSTRACT FROM AUTHOR]

A 2 1/2-year-old girl with bradycardia and left bundle branch block at birth began to experience ‘night cries’ when deeply asleep. Electrophysiological study demonstrated congenital diffuse atrioventricular conduction disease with concealed paroxysmal atrioventricular block, nonpropagated His bundle depolarizations, severe sinus node abnormality, and a low atrioventricular junctional escape rhythm with probable reciprocation. After pacemaker implant, the ‘night cries’ ceased. [ABSTRACT FROM AUTHOR]

Ventricular pacing was performed in forty-one children ranging from one day to twenty years of age (median age = 10). Weight of the recipient at implant ranged from 2 kg. to 86 kg. Indications included presyncope, syncope, dyspnea on exertion, congestive heart failure, postoperative infra-Hisian heart block, and inadequate cardiac rate during pharmacotherapy. Four patients died during follow-up, but no deaths were attributable to pacemaker management. In contrast, 66% of the patients required more than one pacemaker related-operative procedure, and 43% of leads implanted failed by 48 hours. Indications for permanent cardiac pacing in this population at this time are symptomatic congenital AV block, symptomatic sinus node disease, and AV block in the postoperative period. Technological developments which might reduce complications seen in this population and electrophysiologic techniques which may better define indications for pacing in children are also reviewed. [ABSTRACT FROM AUTHOR]

Introduction: Transcatheter radiofrequency ablation is an effective, safe treatment of arrhythmias in children. However, despite technical advances, patients with obstructed venous access to the heart have not been candidates for this treatment. Methods and Results: Two children (8.2 and 10.9 kg) with complex congenital heart disease, supraventricular tachycardia, and obstructed venous access underwent successful radiofrequency ablation of either a right (one patient) or left (one patient) accessory pathway using the transhepatic route to the heart. Conclusion: This experience underscores the usefulness of the transhepatic approach in small patients, in patients with limited venous access, and in patients with complex congenital heart disease. [ABSTRACT FROM AUTHOR]

This article summarizes delayed interruption in anomalous conduction through accessory connections following radiofrequency ablation attempts in three patients. The time course of the delayed interruption in accessory connection conduction suggests that such an effect is unlikely to occur after the first week following unsuccessful radiofrequency ablation. [ABSTRACT FROM AUTHOR]

We report the case of a 10-year-old child with on abdominally implanted epicardial pacemaker that eroded through the peritoneum and migrated to an intrapentoneal location, resulting in partial and then complete intestinal obstruction. This potentially life-threatening complication should be considered when a patient with an abdominally implanted pacemaker presents with abdominal pain. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor expressing the author's reactions to an article on complications from cardiac pacemakers published in the "Pace" periodical in 1996.