Rodríguez-Mañero Moisés, Kreidieh Bahij, Ibarra-Cortez Sergio H, Álvarez Paulino, Schurmann Paul, Dave Amish S, Valderrábano Miguel
Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute The Methodist Hospital Houston Texas.
Cardiology Department Complejo Hospital Universitario de Santiago Santiago de Compostela Spain.
J Arrhythm. 2018 Dec 3;35(1):79-85. doi: 10.1002/joa3.12136. eCollection 2019 Feb.
Elevated defibrillation threshold (DFT) occurs in 2%-6% of patients undergoing implantable cardioverter defibrillator (ICD) implantation. Adding a defibrillation coil in the coronary sinus (CS) or its branches can result in substantial reductions in the mean DFT. However, data regarding acute success and long-term stability remain lacking. We report our experience with this bailout strategy.
Patients with elevated DFT at implantation (safety margin at implantation <10 J) and those with failed ICD shocks for ventricular arrhythmias (VA) referred for high DFT underwent placement of an additional defibrillation coil in the CS. DFT testing was performed at the completion of the implantation procedure. External potentially reversible factors were excluded. High-output devices were systematically used.
Four patients with high DFT at implantation and two with several failed shock attempts underwent placement of a defibrillation coil in the CS. Mean age was 41.8 (23-78). They presented a mean LVEF of 21% (15-30), QRS-complex duration of 109.8 milliseconds (87-168), body surface area of 1.96 m (1.45-2.58), and a mean R wave of 16.3 mV (8-27). Defibrillation coil implantation in the CS (final shocking configuration of right ventricle as anode and left ventricle (LV) plus can as cathode) was associated with successful DFT testing in all. Three patients had a concomitant LV lead for biventricular pacing. During a mean follow-up of 54.67 months (10-118), two patients experienced successful ICD shocks for VA (one of them also presented inappropriate shocks because of the fast conducting atrial fibrillation).
Positioning of a defibrillation coil in the CS can result in a substantial reduction in mean DFT and associates with optimal long-term stability.
在接受植入式心脏复律除颤器（ICD）植入的患者中，2%-6%会出现除颤阈值（DFT）升高。在冠状静脉窦（CS）或其分支中添加除颤线圈可使平均DFT大幅降低。然而，关于急性成功率和长期稳定性的数据仍然缺乏。我们报告了我们使用这种补救策略的经验。
植入时DFT升高（植入时安全裕度<10 J）以及因室性心律失常（VA）导致ICD电击失败且DFT高而转诊的患者，在CS中额外放置了一个除颤线圈。在植入手术完成时进行DFT测试。排除了外部潜在的可逆因素。系统地使用了高输出设备。
4例植入时DFT高的患者和2例多次电击尝试失败的患者在CS中放置了除颤线圈。平均年龄为41.8岁（23-78岁）。他们的平均左心室射血分数（LVEF）为21%（15%-30%），QRS波时限为109.8毫秒（87-168毫秒），体表面积为1.96平方米（1.45-2.58平方米），平均R波为16.3毫伏（8-27毫伏）。在CS中植入除颤线圈（右心室作为阳极，左心室（LV）加外壳作为阴极的最终电击配置）在所有患者中均与DFT测试成功相关。3例患者有用于双心室起搏的LV导线。在平均54.67个月（10-118个月）的随访期间，2例患者因VA接受了成功的ICD电击（其中1例还因快速传导的心房颤动出现了不适当的电击）。
在CS中放置除颤线圈可使平均DFT大幅降低，并具有最佳的长期稳定性。
