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EP News: Case Reports

  • T. Jared Bunch
    Correspondence
    Address reprint requests and correspondence: Dr T. Jared Bunch, Intermountain Heart Rhythm Specialists, Intermountain Medical Center, Eccles Outpatient Care Center, 5169 Cottonwood St, Suite 510, Murray, UT 84107.
    Affiliations
    Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah
    Department of Internal Medicine, Stanford University, Palo Alto, California
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Published:August 26, 2019DOI:https://doi.org/10.1016/j.hrthm.2019.08.002
      Implantation of a traditional implantable cardioverter-defibrillator (ICD) remains a challenge in small children because of their size and the anticipation of skeletal and vascular growth. Subcutaneous ICDs (S-ICDs) do not require leads, but their use in small children is unclear because of the generator size that can cause erosion and one lead size designed for adults. von Alvensleben et al (DOI: https://doi.org/10.1016/j.hrcr.2019.05.004) shared a case of a 5-year-old girl (13.5 kg) who had ventricular fibrillation cardiac arrest. Cardiovascular testing was normal and genetic testing was positive for a pathologic mutation in CALM1c.398G>A (p Glyl33Glu). The authors chose to implant an S-ICD. A subcutaneous pocket in the left axilla was created for the generator. Using the standard tunneling tool, the ICD lead was inserted slightly right of the sternum in a vertical orientation and at the distal aspect they created a left C curve to accommodate the lead redundancy. This C curve was made through a small superior incision that was leftward of the sternum. Defibrillation threshold testing was normal. Over 18 months of follow-up, there was no evidence of erosion in the axillary pocket or appropriate or inappropriate ICD therapies. This case highlights the use of preprocedure vectors to guide device placement and then subtle modifications in techniques to accommodate lead redundancy in small patients.
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