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Angeles University Foundation

College of Nursing
Angeles City

Effective Cardioverter
Defibrillator Implantation in
Children without
Thoracotomy: A Valid
Alternative
Presented By:
Jao Anton R. Ocampo
Group #3
BSN II-A
Presented To:
Clinical Instructors- College of Nursing

Effective Cardioverter Defibrillator Implantation in Children Without


Thoracotomy: A Valid Alternative
Annals of Thoracic Surgery
Bove T et al. The authors propose an alternative method of implanting a cardioverter
defibrillator without the need for associated thoracotomy, based on the subxiphoidal insertion of an
epicardial bipolar ventricular pacing and sensing lead, an active can placed in the abdomen, and a
subcutaneous array tunneled along the left thoracic wall as a shock electrode. This technique
offers the advantage of an effective and minimally invasive implantable cardioverter defribillator
with wide applicability for children, independent of their size and cardiac status.

1. Introduction
Implantable cardioverter defibrillator (ICD) therapy has become a standard in the primary and
secondary prevention of sudden cardiac death [1,2]. At least 10 J safety margin between
intraoperative defibrillation threshold (DFT) testing and maximum output of the ICD device have
become widely accepted practice. Although the safety margin can be achieved in the vast majority
of patients, there are still patients where a 10 J safety margin cannot be confirmed. Whether to
accept even higher DFT or to change the electrical field by insertion of further electrodes remains,
so far, the individual physician's decision. The aim of our study was to analyse the clinical
impression of having a powerful tool for DFT lowering if an additional subcutaneous finger lead is
added to the standard configuration (single-coil RV lead and subpectoral active can).

2. Patients and methods


A total of 2803 consecutive patients underwent either first-time ICD implantation or ICD device
exchange from 6/1999 through 3/2007 at the University of Heidelberg. All patients had a single-coil
RV lead and an active ICD device in subpectoral position. Implanted lead and device manufacturer
were Medtronic, St. Jude, Biotronik and Guidant, respectively Boston Scientific. No other but the
subcutaneous 6996 lead by Medtronic Inc., Minneapolis, USA was used to achieve an altered
electrical field.

3. Results
Out of the 2803 total patients, 177 patients (6.3%) received an additional subcutaneous finger lead
implantation in retrocardiac position (Fig. 1a and b). For insertion of the subcutaneous finger lead,
no additional incision was performed, but the insertion tool was tunnelled from the subpectoral
pocket through the submuscular space around the ribs as close to the spine as possible. It is
important that the subcutaneous finger lead was at about the same height in a.p. fluoroscopy as
the coil of the RV lead. According to the current institutional DFT testing protocol, any failure of the
two standard DFT tests in first-time ICD implantation or a failure at the single test in ICD exchange
operations was the trigger for subcutaneous finger lead implantation. The absolute values changed
over time, since the maximum output of the ICD devices became higher in the more recent period;
a DFT 10 J less to the maximum output of the device was accepted, so in case of a maximum
output of 30 J, a failure at 20 J induced the implantation of an additional subcutaneous finger lead.
The finger lead was inserted in the SVC or HVX DF-1 connector having the same polarity as the
active can which was placed in the standard subclavicular subpectoral pocket.

4. Discussion
In former studies, patches played the major role for DFT lowering. Interestingly, subcutaneous
patch leads decreased DFT by 35% compared with epicardial patch placement in an animal model.
They found in an experimental setting, that even in cases of malpositioned transvenous leads,
which means the RV coil position away from the apex towards the tricuspid valve, a reversal of
DFT increases if subcutaneous arrays are additionally placed in the left thorax.
The higher the number of fingers the lower the effects summarizes a randomized study who
omitted one of the three finger leads; however, the authors did not use a single-coil subcutaneous
lead which would have been potentially even more effective. In conclusion, for DFT lowering the
subcutaneous finger lead seems to represent a very effective method with a minor risk of insertionrelated injury.

Effective Cardioverter Defibrillator Implantation in Children Without Thoracotomy: A


Valid Alternative

I.

Summary
An alternative method of implanting a cardioverter defibrillator without the need for
associated thoracotomy was proposed by Dr. Bove. A total of 2803 consecutive patients
underwent either first-time ICD implantation or ICD device exchange at the University of
Heidelberg. All patients had a single coil RV lead and an active ICD device in subpectoral
position. For insertion of the subcutaneous finger lead, no additional incision was
performed, but the insertion tool was tunneled from the subpectoral pocket through the
submuscular space around the ribs as close to the spine as possible. In studies
conducted, patches played the major role for DFT lowering. Interestingly, subcutaneous
patch leads decreased DFT by 35% compared with epicardial patch placement. An active
can placed in the abdomen, and a subcutaneous array tunneled along the left thoracic wall
as a shock electrode. As such the authors did not use a single-coil subcutaneous lead
which would have been potentially even more effective. It is a technique that offers the
advantage of an effective and minimally invasive implantable cardioverter defribillator with
wide applicability for children, independent of their size and cardiac status.
II. Reaction
Personally, I was able to appreciate the facts that were contained within the article.
It opens the mind of individuals as considering this as an alternative method of implanting
a cardioverter defibrillator without the need for associated thoracotomy. However, this
article needs further development and research. They should be able to compare and
contrast the after effects of this method adjacent to the traditional procedure, which is
performing an incision.
As I read the article, it became more interesting. I learned that this technique offers
the advantage of an effective minimally invasive implantable cardioverter defibrillator with
wide applicability to pediatric patients, which is independent to its size and cardiac status.

To comment with the groups findings, I can say that their data can certainly serve
as basis for improved practice and research in medical health care. It cannot be denied
that they made an excellent study since it changed the traditional method of implantation
of cardioverter defibrillator. However, I became a little bit disappointed since the person
behind the piece was not able to elaborate further the results that they have obtained and
also the number of those studies that contradicted their results. In addition, the time frame
the study has been going; the number of researchers involved; the place and method used
and other important statistical data that were not mentioned too.
I also could not completely agree with the researchers since they have only shown
one side of their study. The article purely contained the advantages and did not present
even a single detriment. Nursing research should be more vibrant, more receptive to social
and health care distribution developments, and more approachable to the public.
Research facilitates how a health care provider will provide services and health care
education programs to the public. Health professionals providing guidance and education
should be familiar with the presented procedure. . Pediatric trainers should be considerate
since they notably improve the competence of the nurses in the management of the
situation. Learning and teaching should be in a continuous process in nursing practice.
Ideal training, educational program and seminars must be required so as to enhance the
competence and knowledge of nurses.

III. Recommendation
This article is apt and beneficial to recommend to nursing students, nurses, and to
other members of the health care team who are the ones who in fact, give quality health
care to patients. If nurses and student-nurses will be able to grasp the datas that were

shown in the study, then it will be of a great help to them since they could provide fresh
information to their patients and the patients family or significant others.
I also suggest the general public to read and examine this work so that they will
know the most up-to-date studies which are or may be sensible to them in times where
they are to encounter the situation mentioned. More so, they could actively comment and
note on the results of the work that then may be functional to others, such as researchers
or interested parties who would like to have the same or related studies.
Other researchers or interested parties must view this as well, for them to do more
comprehensive investigations to either support or oppose the data given here. It will be
greatly appreciated if they will help the authors of the study to expound further the
information that they have gathered.
Lastly, I recommend the researchers of this study to elaborate more. They must add
up more remarkable information, such as the disadvantages of their proposed study by
conducting extra investigation about what they have first studied.
Source: http://ats.ctsnetjournals.org/cgi/content/abstract/89/4/1307

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