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Table of Contents
CASE REPORT  
Year : 2020  |  Volume : 23  |  Issue : 2  |  Page : 235-236
Epicardial cardioverter defibrillator implantation due to post-fontan ventricular tachycardia


1 Department of Cardiothoracic Surgery, General Hospital of Athens “Evangelismos”, Athens, Greece
2 Department of Interventional Cardiology, Red Cross Hospital, Athens, Greece
3 Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden

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Date of Submission11-Dec-2018
Date of Decision20-May-2019
Date of Acceptance22-Jun-2019
Date of Web Publication07-Apr-2020
 

   Abstract 


Long-term survival of patients submitted to a Fontan procedure is reduced because of arrhythmias. Late post-Fontan ventricular tachycardia is extremely rare, but it can be fatal. Consequently, the implantation of an implantable cardioverter defibrillator may be required. The implantation of such a device after a Fontan operation can be rather difficult due to anatomic reasons that exclude transvenous approach. Epicardial ICD implantation is a treatment option for these patients. Transatrial approach, shock ICD coils placement in azygos vein or directly in the pericardium are possible alternatives. We hereby present a successful epicardial implantable cardioverter defibrillator implantation in a post-Fontan 39-year-old man suffering from ventricular tachycardia.

Keywords: Epicardial defibrillator, fontan operation, implantable cardioverter defibrillator, ventricular arrhythmia

How to cite this article:
Papakonstantinou NA, Patris V, Samiotis I, Koutouzis M, Koutouzi G, Argiriou M. Epicardial cardioverter defibrillator implantation due to post-fontan ventricular tachycardia. Ann Card Anaesth 2020;23:235-6

How to cite this URL:
Papakonstantinou NA, Patris V, Samiotis I, Koutouzis M, Koutouzi G, Argiriou M. Epicardial cardioverter defibrillator implantation due to post-fontan ventricular tachycardia. Ann Card Anaesth [serial online] 2020 [cited 2020 Jun 6];23:235-6. Available from: http://www.annals.in/text.asp?2020/23/2/235/282076





   Introduction Top


In case of single-ventricle, Fontan operation is the surgical treatment of choice. Either early or late post-Fontan arrhythmias are frequently observed, but ventricular arrhythmias are rare, although fatal.[1] The latter may be amenable to cardioversion by an implantable cardioverter defibrillator (ICD).[2] However, the implantation of such a device after a Fontan operation can be rather difficult due to anatomic reasons that exclude transvenous approach. As a result, alternative methods for ICD implantation are required.[1] Hereby, we present a 39-year-old patient in whom an epicardial ICD was implantated due to post-Fontan ventricular tachycardia.


   Case History Top


A 39-year-old man was admitted to our emergency department due to palpitations. There was a history of a double inlet left ventricle operated in two stages. A bidirectional Glenn shunt or hemifontan procedure had been performed when he was 6 months old and a Fontan completion operation through an intra-atrial lateral tunnel (ILT) had been performed 14 years later. Ventricular tachycardia (VT) with a 40% ejection fraction was detected. Provided that there was limited venous access for ICD implantation, epicardial implantation via median sternotomy and under general anesthesia was decided.

After troublesome harvesting of the epicardial surface of the heart due to stiff adhesions between the pericardial cavity and retrosternal space, a wide extent of the univentricular heart was exposed. Two unipolar epicardial pacing leads with spherical electrodes for pacing and sensing were secured by sutures [Figure 1]a. An epicardial defibrillation patch (model 6921 Medtronic, Minneapolis, MN) was secured to the surrounding tissue in a halo shape [Figure 1]b. Finally, a 6-cm incision was made in the left upper abdominal quadrant and a subcutaneous pocket to admit the defibrillator was created [Figure 2]. The postoperative course was uneventful and postoperative pain was controlled with paracetamol only. A consent publication form was asked and signed by the patient.
Figure 1: (a) Two unipolar epicardial pacing leads with spherical electrodes for pacing and sensing are secured by sutures; (b) a Halo-shaped epicardial defibrillation patch (model 6921 Medtronic, Minneapolis, MN)

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Figure 2: A 6-cm incision in the left upper abdominal quadrant and a subcutaneous pocket creation

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   Discussion Top


Long-term survival of patients having been treated with a Fontan procedure is undermined because of arrhythmias. The frequency of arrhythmias after Fontan operation increases over time. The most common late post-Fontan arrhythmias are intra-atrial re-entrant tachycardia and sinus bradycardia. Late post-Fontan VT is extremely rare, but it can be fatal in post-Fontan patients.[1] Sudden cardiac death, mainly because of ventricular arrhythmias, is a leading cause of death in patients with congenital heart disease.[2] According to Oechslin's et al. multi-center cross-sectional study, 3.5% of patients suffered from VT after a Fontan procedure.[3] VT probably arise from surgical scars or pre-Fontan longstanding cyanosis and volume overload producing arrhythmiogenic areas.[1]

The conventional transvenous approach for ICD implantation may be rather difficult in patients with congenital heart disease.[1],[4] After a Fontan operation has been performed, transvenous ICD implantation is either anatomically excluded due to tricuspid atresia or is not indicated because of non-functional right ventricle (presence of double inlet left ventricle). So, alternative methods are required.[1] Epicardial ICD implantation is a treatment option for these patients, although it is associated to high operative risk due to the need for extensive harvesting of epicardial surface from firm adhesions. Moreover, it can be only performed under general anesthesia which adds more to the perioperative risk. However, the immediate postoperative course is usually uneventful requiring simple, usual analgesics for pain control. Transatrial approach, shock ICD coils placement in azygos vein or directly on the pericardium are possible alternatives.[4] Finally, a wearable cardioverter-defibrillator can serve as a bridge before the application of a more permanent solution.[5]

Acknowledgements

No grants or funding was received. The authors had full control of the design of the study, methods used, outcome parameters and results, analysis of data, and production of the written report. No conflict of interest was declared.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Agir AA, Celikyurt U, Karauzum K, Yilmaz I, Ozbudak E, Bozyel S, et al. Clinical ventricular tachycardia and surgical epicardial ICD implantation in a patient with a Fontan operation for double-inlet left ventricle. Cardiovasc J Afr 2014;25:e6-10.  Back to cited text no. 1
    
2.
Chubb H, Rosenthal E. Implantable cardioverter-defibrillators in congenital heart disease. Herzschrittmacherther Elektrophysiol 2016;27:95-103.  Back to cited text no. 2
    
3.
Oechslin EN, Harrison DA, Connely MS, Webb GD, Siu SC. Mode of death in adults with congenital heart disease. Am J Cardiol 2000;86:1111-6.  Back to cited text no. 3
    
4.
Cannon BC, Friedman RA, Fenrich AL, Fraser CD, McKenzie ED, Kertesz NJ. Innovative techniques for placement of implantable cardioverter - defibrillator leads in patients with limited venous access to the heart. Pacing Clin Electrophysiol 2006;29:181-7.  Back to cited text no. 4
    
5.
Kutyifa V, Moss AJ, Klein H. Use of the wearable cardioverter defibrillator in high-risk cardiac patients data from the prospective registry of patients using the wearable cardioverter defibrillator (WEARIT-II registry). Circulation 2015;132:1613-9.  Back to cited text no. 5
    

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Correspondence Address:
Nikolaos A Papakonstantinou
12 Zilon Street, Rizoupoli, 11142 Athens
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_234_18

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