Circulation, Vol 87, 1152-1168, Copyright © 1993 by American Heart Association
GH Bardy, B Hofer, G Johnson, PJ Kudenchuk, JE Poole, GL Dolack, M Gleva, R Mitchell and D Kelso
BACKGROUND. Implantable transvenous cardioverter-defibrillators offer a
significant opportunity to decrease procedural morbidity and medical costs
in the care of patients with life-threatening ventricular arrhythmias who
otherwise would have required a sternotomy or thoracotomy for device
insertion. The purpose of this study was to examine prospectively the
safety, efficacy, and limitations associated with the use of a
transvenously implanted, tiered-therapy cardioverter- defibrillator with
antitachycardia pacing function in a consecutive population of 84
ventricular fibrillation (VF) and sustained ventricular tachycardia (VT)
survivors. METHODS AND RESULTS. The index arrhythmia promoting transvenous
cardioverter-defibrillator implantation was VF in 41 patients, VT in 27,
and both VF and VT in 16. In each patient, transvenous defibrillation via a
coronary sinus, a right ventricular, a superior vena caval, and/or a
subcutaneous chest patch lead system was attempted. The pulsing methods
used include two- electrode single-pathway pulsing or three-electrode
dual-pathway simultaneous or sequential pulsing. A transvenous
cardioverter- defibrillator was inserted if the defibrillation threshold
(DFT) was < or = 20 J. Successful implantation of a transvenous
cardioverter- defibrillator was possible in 80 of 84 (95%) patients. The
mean implant DFT was 10.9 +/- 4.8 J. After cardioverter-defibrillator
implantation, all patients were extubated in the operating room and sent to
a standard telemetry ward for monitoring. No patient suffered a
postoperative pulmonary complication or perioperative flurry of cardiac
arrhythmias. Postoperative complications included lead dislodgments in
eight, transient long thoracic nerve injury in one, asymptomatic left
subclavian vein occlusion in two, asymptomatic small pericardial effusion
in one, subcutaneous patch pocket hematomas in four, pulse generator pocket
infection in one, and lead fracture in one. As experience was gained with
the procedure, it was routine to discharge patients 3 days after surgery.
The mean hospital stay was 6.0 +/- 2.4 days. Upon discharge, all patients
returned to their prehospital activities including those with complications
except for the patient with a pocket infection, who required intravenous
antibiotic therapy. Patient survival using an intention-to-treat analysis
was 98% over an 11 +/- 7-month follow-up period. During this time period,
31 of the 80 patients (39%) with transvenous lead systems were successfully
treated by their device for sustained VT or VF. Antitachycardia pacing was
used in 424 episodes of monomorphic VT and was successful in 371 (88%). All
episodes of VF were aborted by the device. Antiarrhythmic drugs were used
after device implantation in only eight of 80 patients (10%). CONCLUSIONS.
Transvenous cardioverter-defibrillator implantation is practical in most
candidates. Implant DFTs are usually low, surgical morbidity and
postoperative complications are modest, therapy of VT and VF is efficient,
and survival is excellent.
ARTICLES
Implantable transvenous cardioverter-defibrillators
Department of Medicine, University of Washington, Seattle.
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