Tonko Johanna B, Blauth Christopher, Rosenthal Eric, Rinaldi Christopher A
Cardiothoracic Unit, Guy's and St.Thomas' NHS Foundation Trust, London, UK.
Faculty of Life Sciences and Medicine, King's College London, London, UK.
Pacing Clin Electrophysiol. 2021 Sep;44(9):1616-1630. doi: 10.1111/pace.14318. Epub 2021 Aug 2.
Epicardial ICD systems and CRT-Ds using high voltage coils represent an alternative to transvenous systems in patients without central venous access and prior device complications including infection.
We present a case series in the adult population of epicardial ICD/CRTD systems using high voltage epicardial coils. We summarize the existing data regarding techniques, efficacy, and safety.
A retrospective board approved medical record review was conducted for all patients undergoing epicardial ICD/CRTD placement at our institution between January 2010 and May 2020. The literature was reviewed for prior published trials, case reports, and case series of epicardial high voltage coil insertions.
Eleven patients (six female, mean age 48 years) underwent epicardial ICD/CRTD implant including 5/11 completely epicardial CRTD systems. The procedure was performed via median sternotomy in eight patients, left anterior thoracotomy in two patients, and sub-xiphoid approach in one patient. After a mean follow up of 35 months, appropriate successful shocks were delivered in two (18%) patients and no patients received an inappropriate shock. Three of five (60%) patients had volumetric remodeling with CRT with significant improvement of LV EF. Device-related complications requiring a surgical/percutaneous revision or another DFT test occurred in six patients (54%). One patient died during follow up due to refractory heart failure. No cases of epicardial device infection, coronary artery compression, constrictive pericarditis, or erosion of defibrillator coils into intrathoracic organs were reported. No randomized studies comparing safety and efficacy of traditional transvenous or subcutaneous ICD systems and epicardial ICD systems using contemporary high voltage coils were found nor any studies directly comparing epicardial defibrillator patches versus epicardial coils. Thirteen case series and 24 single case reports published between 2004 and 2020 were identified describing in total a heterogenous group of 188 patients with ICD systems incorporating one or more epi- or pericardially positioned shock coils.
The use of epicardial defibrillation coils for ICD/CRT-D is a feasible treatment option for patients with either failed or contraindicated transvenous ICD systems. Dedicated epicardial high voltage leads with integrated pace-sense electrodes and specialized delivery tools for minimal invasive implantations may improve longer term outcomes.
对于没有中心静脉通路以及存在包括感染在内的既往器械并发症的患者，使用高压线圈的心外膜植入式心律转复除颤器（ICD）系统和心脏再同步治疗除颤器（CRT-D）是经静脉系统的一种替代方案。
我们展示了一组使用高压心外膜线圈的成人患者心外膜ICD/CRT-D系统的病例系列。我们总结了关于技术、疗效和安全性的现有数据。
对2010年1月至2020年5月期间在我们机构接受心外膜ICD/CRT-D植入的所有患者进行了经机构审查委员会批准的回顾性病历审查。对先前发表的关于心外膜高压线圈植入的试验、病例报告和病例系列的文献进行了回顾。
11例患者（6例女性，平均年龄48岁）接受了心外膜ICD/CRT-D植入，其中5/11为完全心外膜CRT-D系统。8例患者通过正中胸骨切开术进行手术，2例患者通过左前开胸术，1例患者通过剑突下途径。平均随访35个月后，2例（18%）患者接受了适当的成功电击，无患者接受不适当电击。5例（60%）患者中有3例通过心脏再同步治疗实现了容积重塑，左心室射血分数显著改善。6例（54%）患者发生了需要手术/经皮翻修或再次进行除颤阈值测试的器械相关并发症。1例患者在随访期间因难治性心力衰竭死亡。未报告心外膜器械感染、冠状动脉受压、缩窄性心包炎或除颤器线圈侵蚀至胸内器官的病例。未发现比较传统经静脉或皮下ICD系统与使用当代高压线圈的心外膜ICD系统的安全性和疗效的随机研究，也未发现直接比较心外膜除颤贴片与心外膜线圈的任何研究。确定了2004年至2020年期间发表的13个病例系列和24个单病例报告，总共描述了188例使用包含一个或多个心外膜或心包定位电击线圈的ICD系统的异质性患者群体。
对于经静脉ICD系统失败或禁忌的患者，使用心外膜除颤线圈进行ICD/CRT-D是一种可行的治疗选择。带有集成起搏感知电极的专用心外膜高压导线和用于微创植入的专用输送工具可能会改善长期预后。
