ICD terapija kod dece i adolescenata

1
ICD terapija kod dece i adolescenata

• Goran Milašinovic
• PMC, KCS

2
Disclosure
Receive mild to moderate compensation for
lectures and clinical studies from Medtronic, St
Jude Medical, Biotronik and BioControl
Co. Receive no grant from any company.
3
ICD terapija prevencija iznenadne srcane smrti
4
Risk-Stratification for Sudden Cardiac Death
Arrhythmia PVCs VT-NS VT-S VF
Heart Disease Absent Present Present Present
LV Dysfunction Absent Absent Present Present
Potential Risks for SCD Minimal Intermediate Intermediate High
PVCs
VT-NS
PVCpremature ventricular complexes
VT-NSnonsignificant ventricular
tachycardiaVT-Ssignificant ventricular
tachycardia VFventricular fibrillation. Prystow
sky EN. Am J Cardiol. 198861102A-107A.
5
CAST Survival
100
Placebo (N725)
95
Survival ()
90
Encainide or flecainide (N730)
85
P0.0003
450
0
400
500
50
100
150
200
250
300
350
Days After Randomization
CAST Investigators. N Engl J Med.
1989321406-412.
6
EMIAT All-Cause Mortality LVEF and by Group
Ejection fraction 31-40
Probability of Survival
Probability of Survival
Amiodarone Placebo
Ejection fraction lt 30
Months Since Randomization
Months Since Randomization
Julian DG, et al. Lancet. 1997349667-674.
7
CAMIAT All-Cause Mortalityand Nonarrhythmic
Death
Amiodarone Placebo
Cumulative Risk ()
P0.130
Cumulative Risk ()
P0.072
Months Since Randomization
Months Since Randomization
Cairns JA, et al. Lancet. 1997349675-682.
8
Primary Prevention Post-MI Trials
80
70
55
60
54
50
Mortality Reduction w/ICD Rx ()
40
31
30
20
10
0
MADIT227 Months
MADIT-II320 Months
MUSTT127 Months

1. Buxton AE, et al. N Engl J Med.
   19993411882-1890.
2. Moss AJ, et al. N Engl J Med. 19963351933-1940.
3. Moss AJ, et al. N Engl J Med. 2002346877-882.

9
MUSTT Randomized PatientsTotal Mortality
1.0
EP ICD
0.9
0.8
Control
0.7
Event-Free Rate
0.6
EP no ICD
0.5
0.4
Plt0.001
0.3
0.2
0.1
0.0
0
3
6
9
12
15
18
21
24
27
30
33
36
39
42
45
48
51
54
57
60
Months After Enrollment
Buxton AE, et al. N Engl J Med.
19993411882-1890.
10
MADIT Survival by Treatment Groups
1.0
ICD
0.8
0.6
Conventional Therapy
Probability of Survival
0.4
0.2
P0.009
0.0
0
3
6
9
12
15
18
21
24
27
30
33
36
39
42
45
48
51
54
57
60
Months After Enrollment
Moss AJ, et al. N Engl J Med. 19963351933-1940.
11
MADIT-II Survival byTreatment Group
1.0
0.9
Defibrillator Group
0.78
0.8
Probability of Survival
0.7
Conventional Group
0.69
0.6
P0.007
0.5
0
1
2
3
4
Years
Moss AJ, et al. N Engl J Med. 2002346877-882.
12
Secondary Prevention TrialsAVID, CASH, CIDS
80
70
60
50
Mortality Reduction w/ICD Rx ()
40
31
30
28
20
20
10
0
CASH23 Years
CIDS33 Years
AVID13 Years

1. AVID Investigators. N Engl J Med.
   19973371576-1583.
2. Kuck KH, et al. Circulation. 2000102748-754.
3. Connolly SJ, et al. Circulation.
   20001011297-1302.

13
AVID Overall Survival
1.0
Defibrillator Group
0.8
Antiarrhythmic Drug Group
0.6
Plt0.02
Proportion Surviving
0.4
0.2
0.0
2
3
0
1
Years After Randomization
AVID Investigators. N Engl J Med.
19973371576-1583.
14
CIDS Update 11-Year Follow-Up
100 80 60 40 20 0
Actuarial Survival ()
P0.021
ICD Amiodarone
20 40 60 80
100 120 140
Months
Bokhari FA, et al. Circulation. 2002106(19 suppl
II)II-497.
15
Primarna prevencija iznenadne srcane smrti kod
dece

• Hipertroficna ili Dilatativna CMP
• Faktori rizika
• 1. Istorija sinkopa u porodici
• 2. Znacajna hipertrofija LK
• 3. NSVT na holteru
• 4. Pad TA prilikom testa opterecenjem
• 2 od 4
  ICD

• From SURGERY for CONGENITAL HEART DEFECTS, 3rd
  Ed., Editors J STARK, M. de LEVAL and VT TSANG

16
Primarna prevencija iznenadne srcane smrti kod
dece

• Long QT sy. (LQTS), koji ne reaguje na
  beta-blokatore ili ne mogu da se uzimaju.

• From SURGERY for CONGENITAL HEART DEFECTS, 3rd
  Ed., Editors J STARK, M. de LEVAL and VT TSANG

17
Primarna prevencija iznenadne srcane smrti kod
dece

• Long QT sy. (LQTS) Polimorfna VT

• From SURGERY for CONGENITAL HEART DEFECTS, 3rd
  Ed., Editors J STARK, M. de LEVAL and VT TSANG

18
Primarna prevencija iznenadne srcane smrti kod
dece

• CPVT (kateholamin-senzitivna (ili zavisna)
  polimorfna VT).

• From SURGERY for CONGENITAL HEART DEFECTS, 3rd
  Ed., Editors J STARK, M. de LEVAL and VT TSANG

19
Primarna prevencija iznenadne srcane smrti kod
dece

• Brugada sy.

Genetska bolest koju karakteriše abnormalan EKG i
povišen rizik za iznenadnu srcanu smrt. Celularna
elektricka aktivnost izmenjena zbog izlaska
natrijuma iz celija.

• From SURGERY for CONGENITAL HEART DEFECTS, 3rd
  Ed., Editors J STARK, M. de LEVAL and VT TSANG

20
ISS kod adolescenata i mladih sportista

• Cardiomyopathies
• Dilated
• Hypertrophic
• Right ventricular dysplasia
• Electrical abnormalities
• Long-QT syndromes
• Brugada syndrome
• W-P-W syndrome

• Viral myocarditis
• Abnormal coronary arteries
• Drug-induced arrhythmias
• Inflammatory/
• infiltrative diseases
• Idioventricular fibrillation
• Diseases of heart valves

From Ventricular Arrhythmias and Sudden Cardiac
Death. Edited by Paul J. Wang, Chapter 17,
Epidemiology and etiologies of sudden cardiac
death, Keane K. Lee et al, 2008
21
01 d 94155
13 d 92158
37 d 90166
730 d 107182
13 mo 120179
36 mo 106186
612 mo 108168
13 yr 90152
35 yr 73137
58 yr 64133
812 yr 63130
1216 yr 61120
Normalna srcana frekvenca kod dece
From Davignon A, Rautaharju P, Boisselle E, et
al Normal ECG standards for infants and
children. Pediatr Cardiol 1123-152, 1979.
22
Srcana fr. i intervali kod dece

• Godine Fr PR
  interval QRS interval
• 1 - 3 nedelje 100 - 180 .07 - .14
  .03 - .07
• 1 - 6 meseca 100 - 185 .07 - .16 .03
  - .07
• 6 - 12 meseci 100 - 170 .08 - .16 .03
  - .08
• 1 - 3 godine 90 - 150 .09 - .16
  .03 - .08
• 3 - 5 godine 70 - 140 .09 - .16 .03
  - .08
• 5 - 8 godine 65 - 130 .09 - .16 .03
  - .08
• 8 - 12 godine 60 - 110 .09 - .16 .03
  - .09
• 12 - 16 godina 60 - 100 .09 - .18
  .03 - .09
• Adapted from Benson, D.W. (1989). The normal
  electrocardiogram. In G.C. Emmanouilides, H.D.
  Allen, T.A. Riemenschneider, H.P. Gutgesell
  (Eds.), Moss and Adams heart disease in infants,
  children, and adolescents (5th ed.) (pp.
  152-164). Baltimore Williams Wilkins.

23
VA SCD in Pediatric Patients

• An ICD should be implanted in pediatric survivors
  of a cardiac
• arrest when a thorough search for a correctable
  cause is negative
• and the patients are receiving optimal medical
  therapy and have
• reasonable expectation of survival with a good
  functional status for
• more than 1 year.
• Hemodynamic and EP evaluation should be performed
  in the young
• patient with symptomatic, sustained VT.
• ICD therapy in conjunction with pharmacological
  therapy is
• indicated for high-risk pediatric patients with a
  genetic basis (ion
• channel defects or cardiomyopathy) for either SCD
  or sustained
• ventricular arrhythmias. The decision to implant
  an ICD in a child
• must consider the risk of SCD associated with the
  disease, the
• potential equivalent benefit of medical therapy,
  as well
• as risk of device malfunction, infection, or lead
  failure
• and that there is reasonable expectation of
  survival

24
VA SCD in Pediatric Patients

• ICD therapy is reasonable for pediatric patients
  with
• spontaneous sustained ventricular arrhythmias
  associated
• with impaired (LVEF of 35 or less) ventricular
  function who
• are receiving chronic optimal medical therapy and
  who have
• reasonable expectation of survival with a good
  functional
• status for more than 1 year.
• Ablation can be useful in pediatric patients with
  symptomatic
• outflow tract or septal VT that is drug
  resistant, when the
• patient is drug intolerant or wishes not to take
  drugs.

25
VA SCD in Pediatric Patients

• Pharmacological treatment of isolated PVCs in
  pediatric
• patients is not recommended.
• Digoxin or verapamil should not be used for
  treatment of
• sustained tachycardia in infants when VT has not
  been
• excluded as a potential diagnosis.
• Ablation is not indicated in young patients with
• asymptomatic NSVT and normal ventricular function.

26
Epikardno ili transvenski

• Indikacije za permanentu epikardnu
• stimulaciju u dece.
• lt 8 kg
• Desno-levi šant
• Problem sa venama
• Više tipova hirurških rešavanja srcanih mana
  podrazumevaju prethodnu implantaciju pejsmejkera
• Opstrukcija VCS
• Težak pristup DK
• Mehanicka trikuspidna valvula
• Neuspeli transvenski pristup

• From SURGERY for CONGENITAL HEART DEFECTS, 3rd
  Ed., Editors J STARK, M. de LEVAL and VT TSANG

27
Epikardno vs. Endokardno

• Transvenous
• Advantages
• Avoid Thoracotomy
• Lower Pacing Thresholds
• Lower incidence of Exit Block
• Disadvantages
• Higher Dislodgement Rates
• Potential for Venous Occlusion
• Risk for Embolic Vascular Event
• Risk of Subclavian Crush
• Endocarditis
• Potential for Tricuspid Valve damage

• Epicardial
• Advantages
• Avoiding concerns of Venous Thrombus
• Disadvantages
• Having to enter the chest cavity
• Poor pacing and sensing thresholds

From presentation on Pediatric Pacing by
Christine Youngs.
28
Comparison of epicardial with endocardial electrode use in children. Note the gradually increasing use of endocardial electrodes. (Data from the Midwest Pediatric Pacemaker Registry.)

29
CAPSURE EPI Leads

• White ring on 4968 identifies cathode leg
• Suture-down holes

4965
Surgical Approach a. Subxiphoid b. Left Lateral
Thoracotomy c. Median Sternotomy d. Other
approaches include Subcostal Right
Thoracotomy
4968
30
SelectSecure System

• 3830
• 4.1 french lumen-less catheter-delivered lead

• C315 delivery catheters for 3830 leads
• Inner diameter 5.5 Fr
• Outer diameter 7.0 Fr

Pacemaker leads with smaller body design may
help in preservation of venous patency in
children. Implantation of SelectSecure Leads in
Children, PACE 7/07 VOLKAN TUZCU, M.D.
31
Transvenous Lead Slack

• Extra lead slack is usually left in the pediatric
  patients atrium to allow for growth
• Adhesions can still form preventing lead slack
  from helping
• Following slides show slack being taken up as
  patient grows

• Graphic From SURGERY for CONGENITAL HEART
  DEFECTS, 3rd Ed., Editors J STARK, M. de LEVAL
  and VT TSANG

32
From Cardiac Pacing, Defibrillation, and
Resychronization A Clinical Approach, 2008, 2nd
Ed., pg. 187, Daniel L. Hayes and Paul A. Friedman
33
Pediatric ICD System Implant Case Studies
34
Photo 2 Weeks Post-Op
From Extracardiac ICD implantation in an infant,
T. Kriebel et al., Zeitschrift für Kardiologie,
Band 94, Heft 6 (2005)
35
Use of Transvenous Lead tunneled to abdominally
placed ICD
Chest radiograph showing placement of a single-coil transvenous defibrillator system with the lead tunneled down the lateral chest wall to the device, which also serves as the second defibrillation electrode and is placed in a left upper quadrant abdominal pocket.

36
Programiranje ICD u dece

• ICD VR, zbog velicine
• Jedna zona detekcije, jer su najcešce indikacije
  kod dece VF, a ne VT (re-entry) Pain-free
  studija nije studirana kod dece.
• Max. SVT diskriminator
• Jedan elektrodni vodic da se izbegne venska
  opstrukcija

37
Case Report 2001

• 14 god, ženski pol
• Abdominalni ICD sa 10 god.
• Indikacija VT 170, operisana ToF sa 2 god.
• Intravenska lektroda subkutani pac u aksili

38
Age 10
Subcut. patch
ICD
39
On the age 14
40
Age 14
41
Subcutaneous lead
Pg
42
Jap. Circulation, 2005
43
Zakljucak

• Najcešca indikacija primarna prevencija
• Sekundarna prevencija kod operisanih USM
• ICD na tržišitu primenjivi za decu
• Cesto korišcenje epikardnih i supkutanih
  elektroda
• Programiranje drukcije nego kod odraslih