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INTRODUCTION The Fontan procedure, used to palliate univentricular physiology, eliminates direct venous access to the ventricle and complicates implantable cardioverter-defibrillator (ICD) placement. METHODS AND RESULTS We describe two patients with Fontan palliation who underwent a novel transvenous approach to ICD placement. The approach uses a transvenous bipolar lead placed in a coronary sinus branch for ventricular sensing, and a defibrillation lead placed in the right atrium for atrial sensing and ventricular defibrillation. CONCLUSION Transvenous ICD implantation is possible in some patients with an atriopulmonary Fontan. This approach avoids a redo sternotomy for epicardial leads and excludes the need for lead placement in the systemic circulation.

BACKGROUND: Atrial fibrillation (AF) is a common comorbidity in patients with left ventricular assist devices (LVAD) with no defined guideline treatment strategy of rate versus rhythm control. The purpose of this study is to determine the effects of rate versus rhythm control for AF on the outcomes of patients with LVAD at our institution. METHODS: Consecutive patients who underwent LVAD implantation at St Vincent Hospital from January 1, 2015 to December 31, 2017 were retrospectively evaluated. Patients with AF were identified and divided into rate control or rhythm control groups. The primary outcome evaluated was a composite of death, heart failure admission, gastrointestinal bleed, ventricular tachycardia, cerebrovascular accident, hemolysis, and pump thrombosis. Secondary outcomes included the individual variables from the primary outcome. RESULTS: Out of 201 patients that underwent LVAD implantation, 81 had AF after implantation and were included with a median follow-up period of 384 days. The rate control group (n = 31; 38%) and the rhythm control group (n = 51; 62%) had no difference in composite outcomes (61% vs 59%, p = 0.83). When taken individually there was no difference in outcomes between the two groups. Thirteen patients underwent electrical cardioversion and successful conversion to normal sinus rhythm occurred in 71% of cases with a 60% recurrence rate. CONCLUSIONS: There was no difference in primary outcome between rate and rhythm control groups. These data suggest that maintenance of sinus rhythm may not be necessary in all patients with LVAD.