Nothing inside the heart – Combining epicardial pacing with the S-ICD

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Presentation transcript:

Nothing inside the heart – Combining epicardial pacing with the S-ICD Christian Steinberg, MD, Santabhanu Chakrabarti, MD, FHRS, Andrew D. Krahn, MD, FHRS, Jamil Bashir, MD, FRCSC HeartRhythm Case Reports Volume 1, Issue 6, Pages 419-423 (November 2015) DOI: 10.1016/j.hrcr.2015.04.001 Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 1 Chest radiographs before and after implantation of subcutaneous implantable cardioverter-defibrillator (S-ICD) and permanent epicardial pacemaker. A: Lateral chest radiograph of the transvenous dual-chamber ICD system prior to extraction. B: Posterior-anterior chest radiograph post implantation of S-ICD and permanent epicardial pacemaker. The 2 epicardial atrial electrodes are fixed to the free wall of the right atrium (bold white arrows). The 2 ventricular electrodes of the epicardial pacemaker are fixed to the inferior and anterior surface of the right ventricle, respectively (bold black arrows). The can of the S-ICD is positioned in a subcutaneous pocket at the lower left-lateral thorax (dashed white arrow). The S-ICD lead is placed in a right parasternal position (black arrowheads). C: Shown are the 3 bipolar sensing vectors of an S-ICD. The primary vector senses between the proximal lead electrode and the can. The secondary vector senses between the distal lead electrode and the can. The alternate vector senses between the 2 lead electrodes. HeartRhythm Case Reports 2015 1, 419-423DOI: (10.1016/j.hrcr.2015.04.001) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 2 Sensing findings at implantation of the subcutaneous implantable cardioverter-defibrillator (S-ICD). A: Higher atrial pacing output (3.5 V/0.4 ms) by the epicardial pacemaker resulted in detection of atrial pacing and double counting through the S-ICD in the secondary sensing vector, but not in the primary sensing vector (C). B: Lowering of the atrial pacing output to 1.5 V/0.4 ms eliminated double counting through the S-ICD in the secondary sensing vector. HeartRhythm Case Reports 2015 1, 419-423DOI: (10.1016/j.hrcr.2015.04.001) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 3 Defibrillation threshold testing. A: Ventricular fibrillation (VF) was induced with a 50 Hz train through the subcutaneous implantable cardioverter-defibrillator (S-ICD). The VF induction was not detected by the epicardial dual-chamber pacemaker and continued pacing is recorded during the VF induction. B: Subsequently appropriate VF detection by the epicardial pacemaker. Despite several attempts, the inducible VF was self-terminating before shock delivery through the S-ICD. RA = right atrial. HeartRhythm Case Reports 2015 1, 419-423DOI: (10.1016/j.hrcr.2015.04.001) Copyright © 2015 Heart Rhythm Society Terms and Conditions