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This report describes the implantation of a transcutaneous ICD system using a small patch electrode in the subscapular position, and an active-can device in a 5.3-kg infant. The indication for ICD implantation was recurrent cardiac arrest in the presence of normal coronary anatomy. Metabolic evaluation suggested a defect in fatty acid oxidation.

Implantable pacemaker cardioverter defibrillators are now available with biphasic waveforms, which have been shown to markedly improve defibrillation thresholds (DFTs). However, in a number of patients the DFT remains high. Also, DFT may increase after implantation, especially if antiarrhythmic drugs are added. We report on the use of a subcutaneous patch in the pectoral position in 15 patients receiving a transvenous defibrillator as a method of easily reducing the DFT. A 660-mm2 patch electrode was placed beneath the generator in a pocket created on the pectoral fascia. The energy required for defibrillation was lowered by 56% on average, and the system impedance was lowered by a mean of 25%. This maneuver allowed all patients to undergo a successful implant with adequate safety margin.

Since the observation by Haissaguerre et al that triggers of atrial fibrillation (AF) mapped to the pulmonary veins (PVs), circumferential PV isolation has become the cornerstone of most AF ablation strategies. As efforts have been made to improve the efficacy and safety of PV isolation, there also has been a push to simplify the circumferential ablation process in order to reduce the learning curve and expedite this time-consuming procedure. The ongoing challenge of the catheter-based ablation procedure remains: How can we best deliver a complex lesion set in a beating heart? As with all procedures, the answer lies in the interplay of the operator’s skills and the available tools. For many years, the only available technology for ablation involved a focal catheter, delivering unipolar radiofrequency (RF) energy between the catheter tip and a surface patch electrode. The first major technological improvement in AF ablation involved saline irrigation of the focal RF catheter. By reducing the temperature at the electrode-tissue interface, irrigation reduced the incidence of char formation and simultaneously enabled higher power delivery. Despite the advent of steerable sheaths, a high level of manual skill is still required for precise point-to-point movement of the focal ablation catheter in order to achieve a truly contiguous lesion set, which remains a time-consuming procedure. Given the approximately circular shape of the PV ostia, more recent ablation platforms have logically been built with circumferential energy delivery. Of the balloon-based ablation platforms, the high-intensity focused ultrasound balloon has been largely abandoned owing to safety concerns. The laser balloon continues to undergo clinical evaluation in the United States. As a true single-shot PV isolation tool, the cryoballoon has achieved widespread use in recent years, with efficacy and safety data comparable to those of focal RF ablation. Other variations of this theme have combined the circular mapping catheter and the focal ablation catheter into 1 tool, obviating the need for a second transseptal catheter. Furthermore, since energy delivery to each circumferential electrode is individually controlled, these platforms allow the choice of

Pericardial constriction associated with the placement of intrapericardial defibrillator patches is a rare occurrence that is reported only one tenth as often in defibrillator patients as in patients undergoing other types of cardiac operations. Although this discrepancy may be attributable to a lower incidence of constriction with the defibrillator patch electrode procedure, it may also indicate a failure to recognize that progressive right heart failure and signs of low cardiac output that could be due to pericardial constriction and not progressive systolic dysfunction. Because surgical removal of the patches and decortication of the epicardial surface is the only effective therapy, it is important to recognize this uncommon, but profoundly debilitating entity.

A new 83 cm3 implantable cardioverter-defibrillator (ICD) designed for pectoral implantation has been implanted most frequently using right ventricular and superior vena cava (RV--SVC) electrodes; a patch electrode (RV--patch + SVC) has been added when necessary to decrease the defibrillation threshold (DFT). The goal of this prospective study was to compare biphasic waveform DFTs for 3 electrode configurations: RV--patch, RV--SVC, and RV--patch + SVC in 25 consecutive patients. The patch was positioned in a left retro-pectoral pocket, and the SVC electrode was positioned with the tip at the junction of the SVC and innominate vein. In the first 15 patients, all 3 electrode configurations were tested in random order; in the last 10 patients, only the RV--patch and RV--patch + SVC configurations were tested. In the first 15 patients, the stored-energy DFT for the RV--SVC configuration (15.2 +/- 7.7 J) was higher (p0.001) than the DFT for the RV--patch configuration (11.3 +/- 6.2 J) and the RV--patch + SVC configuration (10.0 +/- 5.8 J). For all 25 patients, the DFT was lower for the RV--patch + SVC configuration (9.7 +/- 5.1 J) than for the RV--patch configuration (12.4 +/- 6.6 J, p = 0.005). The pathway resistance was highest for the RV--patch configuration (72 +/- 9 omega), lower for the RV--SVC configuration (63 +/- 6 omega, p0.01), and lowest for the RV--patch + SVC configuration (46 +/- 3 omega, p0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Previous studies have shown that low internal defibrillation thresholds (DFTs) can be attained by using two pairs of electrodes and combining biphasic shocks with sequential timing. The purpose of this two-part study was to test the defibrillation efficacy of two new shock sequences, an interleaved biphasic, and a common phase sequential biphasic, that utilized two pairs of electrodes and were developed from the concept of sequential biphasic shocks. In the first part, defibrillation catheters were placed in the right ventricle and the superior vena cava of six anesthetized pigs. A small patch electrode was placed on the LV apex through a subxiphoid incision and a cutaneous patch was placed on the left thorax. The mean DFT energies for the interleaved biphasic (5.2 +/- 0.4 J) and the common phase sequential biphasic waveforms (5.4 +/- 0.4 J) were substantially less (P < 0.0001) than those for either the sequential monophasic (10.6 +/- 1.0 J) or single biphasic waveforms (9.0 +/- 1.0 J). In the second study, which used nine anesthetized pigs, the importance of phase reversal was demonstrated by the finding that the DFT energy of a common phase sequential biphasic shock (6.2 +/- 0.4 J) was much less than a common phase sequential monophasic shock (17.9 +/- 1.3 J, P < 0.0001); furthermore, the average DFT for four common phase sequential biphasic configurations (5.7 +/- 0.2 J) was much less than for a configuration that was similar except that current flow was not reversed in one phase so that no biphasic effect was present (19.7 +/- 1.2 J). The efficacy of common phase sequential biphasics was comparable to that of sequential biphasics. The effectiveness of sequential biphasics, interleaved biphasics, and common phase sequential biphasics is possibly due to two mechanisms: (A) an increase in the potential gradient during a later phase in regions that were low during the first phase, and (B) the exposure of most of the myocardium to a biphasic shock that reduces the minimum extracellular potential gradient needed to defibrillate.

Cardioverter-defibrillator implantation in 22 consecutive patients after aborted sudden cardiac death was followed by prospective determination of the correct anatomic position of epicardial patch electrodes by chest X-ray study and cine computed tomography; the data were compared with the defibrillation threshold obtained intraoperatively. Patch electrode position was qualitatively graded. Computed tomography improved the assessment as compared with X-ray study in 13 patients (59%), visualizing electrodes in relation to the underlying myocardial and vascular structures. Although the computed tomographic technique provided more precise visualization, its grading of patch position correlated as poorly as that of the X-ray study with the measured acute defibrillation threshold. Three-dimensional reconstruction by computed tomography made it possible to determine quantitatively left ventricular mass (free wall and septum) and the mass encompassed by the patch electrodes. The 34.6 ± 13.7% (range 12.6 to 61.1%) of the left ventricular mass encompassed by both patch electrodes showed a linear relation to the defibrillation threshold (r = 0.64, p = 0.01). Differentiation of free wall and septal mass in these measurements revealed that the proportion of septal mass encompassed by patch electrodes correlated closely with the defibrillation threshold (r = −0.6, p = 0.019), whereas that of the free wall mass, although significantly larger (35.4 ± 15.8 vs. 20.6 ± 15.4 g, p = 0.007), did not. Thus, the position of epicardial patch electrodes could be reliably determined by computed tomography. Although the tomographically measured fraction of left ventricular mass encompassed by patch electrodes was predictive of defibrillation threshold, for achievement of a low threshold, it was more important to include the interventricular septal mass than the free wall mass.

There are many known complications of implantable cardioverter-defibrillator placement. We treated a patient in whom a left ventricular pseudoaneurysm developed secondary to epicardial patch electrode placement and cardioverter-defibrillator implantation. The presenting symptoms, diagnostic evaluation, and surgical repair are described.

There are more than 20 years of experience with implantation of defibrillator devices in humans and the procedure is an important therapeutic option for patients at high risk of life-threatening ventricular arrhythmias. The incidence of new defibrillator implantation has gradually increased, being used even in children, 1 although pediatric use is associated with several complications, especially with epicardial systems,2 including fracture of the subcutaneous patch,3-5 mainly because of growth.3 We present a case of subcutaneous patch electrode fracture in the left axillary pectoral region of a patient who needed the patch for effective defibrillation, and we discuss the methods of treatment. (Circ J 2005; 69: 116 -118)

The patch electrode and the array electrode are the two types of subcutaneous leads available as an adjunct to a transvenous lead system in patients with high defibrillation thresholds. A prospective randomized study was conducted in 30 consecutive patients comparing the efficacy and the long-term performance of a patch electrode with an array electrode. After determination of the defibrillation threshold for the transvenous lead alone, a subcutaneous patch or an array electrode was implanted in random order. Adding a patch electrode decreased the defibrillation threshold in seven out of 15 patients (47%) from 13.2+/-6.6 to 10.5+/-5.1 J (P0.05). In 13 out of 15 patients (87%), the implantation of an array electrode caused a significant lowering of the defibrillation threshold from 15.4+/-6.6 to 8.2+/-5.0 J (P0.0001). The array electrode was significantly more effective in lowering the defibrillation threshold than the patch electrode (P0.01). Complications during follow-up associated with the subcutaneous patch electrode were observed in four patients whereas no complications were associated with the array electrode (P0.01). The additional implantation of an array electrode is more effective and associated with fewer complications compared to a patch electrode.

We studied a new technique for creating long linear lesions in hearts using a custom-made linear probe. Radiofrequency (RF) energy applications using a 25-mm long stainless steel linear probe and a corresponding 500-kHz energy generator were tested, creating 90 lesions in isolated porcine hearts. The RF current was applied between the linear probe and a large patch electrode attached to the back of the specimen. Three parameters, comprising the power of the delivered energy, the pressure of contact between the probe and the specimen, and the duration of energy delivery were changed independently and the size of the resulting lesions was measured. All 90 lesions were transmural, well demarcated and created by a single stationary RF application. Lesion length and width increased with: 1) increasing power, when the other two parameters were maintained at constant levels, 2) increasing contact pressure, when the other two parameters were maintained at constant levels, and 3) increasing duration of energy delivery when the other two paramaters were maintained at constant levels. The maximum width of the lesions was 3.7 mm. No overheating of any of the specimens was observed. In conclusion, the new original long linear probe used in this study was effective for creating transmural linear lesions, presenting the possibility of a worthwhile contribution to the maze surgical procedure applied to atrial fibrillation.

Successful implantation of a biphasic nonthoracotomy implantable cardioverter defibrillator may not be achieved with a conventional system. We describe a successful device implantation using a pectoral and abdominal patch electrode system.

Nonthoracotomy defibrillator systems can be implanted with a lower morbidity and mortality, compared to epicardial systems. However, implantation may be unsuccessful in up to 15% of patients, using a monophasic waveform. It was the purpose of this study to prospectively examine the efficacy of a second chest patch electrode in a nonthoracotomy defibrillator system. Fourteen patients (mean age 62 +/- 11 years, ejection fraction = 0.29 +/- 0.12) with elevated defibrillation thresholds, defined as > or = 24 J, were studied. The initial lead system consisted of a right ventricular electrode (cathode), a left innominate vein, and subscapular chest patch electrode (anodes). If the initial defibrillation threshold was > or = 24 J, a second chest patch electrode was added. This was placed subcutaneously in the anterior chest (8 cases), or submuscularly in the subscapular space (6 cases). This resulted in a decrease in the system impedance at the defibrillation threshold, from 72.3 +/- 13.3 omega to 52.2 +/- 8.6 omega. Additionally, the defibrillation threshold decreased from > or = 24 J, with a single patch, to 16.6 +/- 2.8 J with two patches. These changes were associated with successful implantation of a nonthoracotomy defibrillator system in all cases. In conclusion, the addition of a second chest patch electrode (using a subscapular approach) will result in lower defibrillation thresholds in patients with high defibrillation thresholds, and will subsequently increase implantation rates for nonthoracotomy defibrillators.

We performed a blinded controlled analysis of transthoracic echocardiograms on IK patients before and after epicardial defibrillator patch electrode placement to determine the accuracy of echocardiography in identifying defibrillator patches and to determine possible echocardiographic findings that may correlate with defibrillator function or perioperative complications. The sensitivity of two-dimensional echocardiography in detecting defibrillator electrodes was 72% by one observer and 39% by a second observer. Corresponding specificities were 67% and 83%, respectively. The discordance rate was 27%. The echocardiographic finding of patch buckling was not observed, and echocardiographic estimates of the distance from patch to epicardium did not correlate with defibrillator threshold at the time of surgery. We conclude that: echocardiography is only moderately sensitive and specific in identifying epicardial defibrillator electrodes; significant interobserver variability does exist; and echocardiography therefore cannot be used reliably to assess for pericardia] changes or possible complications of patch electrode placement.

Placement of Implantable cardioverter devices in young children is complicated because of the relatively large size and heavy weight of these devices. A technique is described where the device is implanted in the left perirenal space while an endovascular lead is used instead of an epicardial patch electrode.

A surgical approach is described for a more cosmetically acceptable placement of the automatic implantable cardioverter-defibrillator in young women. The transvenous sensing lead and the vena caval spring electrode are placed through a small subclavicular incision. The left ventricular patch electrode is placed through an anterior minithoracotomy in the crease under the left breast. A small transverse incision in the left lower quadrant is used to place the generator under the external oblique fascia in the low abdominal wall. Minimal cosmetic impairment from incisions and hardware results.

The mechanism underlying the Ba2+-induced automaticity was studied in isolated guinea pig ventricular myocytes using the whole-cell clamp method and a patch electrode. In the presence of 0.1–0.3 mM Ba2+, application of a weak depolarizing current induced repetitive firing of spontaneous action potentials. Application of tetrodotoxin or Ca2+ channel blockers and removal of external Na+ and Ca2+ did not abolish the rhythmic activity, thereby suggesting that activation of inward currents played no crucial role in the generation of this rhythmicity. Voltage-clamp studies revealed that Ba2+ blocked the inward rectifier K+ current (iK1) in a voltage- and time-dependent manner with a greater and more rapid block at more negative potentials. This Ba2+ action could quantitatively be fitted with a model of the conventional bimolecular adsorption isotherm with a voltage-dependent dissociation constant. Simulation studies using this model showed that a membrane model, in which only the iK1 system and a small leak conductance were incorporated, could reproduce an automatic activity similar to that seen experimentally. Thus, in isolated ventricular cells, the voltage- and time-dependent block of iK1 by Ba2+ appears to be one important mechanism underlying the automaticity.

Objectives. This study analyzed the advantage of combining a biphasic device with a transvenous system and compared the results with those obtained with a standard monophasic device. Background. Available lead system use monophasic pulses and may require lengthy intraoprative testing to achieve adequate defibrillation threshold in a conspicuous number of patients. The option of biphasis waveform may provide further benefits. However, clinical experience with a permanent implant is lacking. Methods. Fifty-five patients underwent testing and received a permanent implant using the Endotak lead system associated with a CPI monophasic device. The remaining 36 patients received a permanent implant with the Endotak lead system connected to a biphasic device. In both groups a subcutaneous patch was combined when needed to obtain acceptable defibrillation thresholds. Results. Biphasic pulses resulted in lower mean (±SD) defibrillation threshold (monophasic 15 ± 4.7 J vs. biphasic 12 ± 5 J, p = 0.03) and a better implantation rate (100% biphasic vs. 89% monophasic, p = 0.07). Biphasic pulses allowed implantation with less ventricular fibrillation induction (7.4 ± 3.2 vs. 3.5 ± 1.8, p < 0.01) and a mean shorter procedure time (168 ± 39 vs. 111 ± 30 min, p < 0.01). With the biphasic waveform a grater proportion of patients met the implantation criteria with the lead system alone (83% vs. 45%, p < 0.01). When needed, the left prepectoral location of the patch electrode was always sufficient in patients receiving the biphasic device, whereas placement in the left subscapular position was required in 15 patients in the monophaisic group. Implantation of the biphasic device was associated with a shorter mean hospital stay (3.8 ± 0.8 vs. 5.4 ± 2.2 days, p < 0.01). Conclusions. Incorporation of a biphasic device in a transvenous implantable cardioverter-defibrillator uniformly incresses the efficacy of the system and the case of implantation.

The traditional assessment of the energy required for successful ventricular defibrillation involves the measurement of a "defibrillation threshold" (DFT), implying a clear-cut distinction between effective and ineffective energies. We examined the relationship between delivered energy and the likelihood of successful defibrillation in 10 open-chest pentobarbital anesthetized dogs, with the use of an internal spring/patch electrode system. An initial DFT was determined by decreasing the energy discharged until a failure first occurred (10.3 +/- 3.4 J). Six energy levels in 1 to 2 J increments were then selected surrounding this value and each was administered eight times in balanced random order (total 48 trials). The relationship between energy and percent success in defibrillation exhibited a shallow slope, with a gradual increase in success from 0% to 100% over several energy increments. The initial DFTs showed actual success rates varying from 25% to 87.5% (mean 71 +/- 26%). The results were fitted to a sigmoidal dose-response curve by logistic regression analysis and the energy associated with 50% success (E50) and 80% success (E80) was determined, as no single value for DFT could be defined in any animal. In 12 other dogs, a defibrillation curve was similarly constructed at baseline and was repeated after 90 minutes. No significant change in E50 (5.0 +/- 2.1 J vs 5.2 +/- 2.7 J) or E80 (6.3 +/- 2.5 J vs 6.6 +/- 3.2 J) was observed.(ABSTRACT TRUNCATED AT 250 WORDS)