How to minimize peri-procedural complications during subcutaneous defibrillator implant?

ABSTRACT

Introduction

Subcutaneous defibrillator (S-ICD) is the latest development in the clinically available devices for sudden cardiac death prevention. Experience from pivotal trials and post-marketing studies has proven the feasibility and safety of S-ICD. Extra-cardiac location of S-ICD obviates the need for transvenous leads which translates into lower incidence of lead-related complications and systemic infections. This is a review on peri-procedural interventions to minimize complications associated with S-ICD during implant and follow-up.

Areas covered

This paper will highlight the results of pertinent studies related to perioperative management of S-ICD and review the approaches to minimize the risk of complications such as hematoma at the pulse generator location, unsuccessful defibrillation due to suboptimal S-ICD lead and generator position, postoperative pain, inappropriate shocks due to T wave oversensing and interaction with concomitant cardiac implantable devices. An extensive literature search was performed to identify the relevant articles.

Expert commentary

The use of S-ICD is expanding, and the published results suggest a preferential use of such devices for younger patients and those with a potential risk of infection from intravascular devices. The perioperative management of S-ICD has significantly evolved during a decade of experience. Contemporary experience suggests that these procedures are associated with minimal complications.

KEYWORDS:

• Perioperative complications
• subcutaneous defibrillator
• sudden cardiac death
• device infection
• intra-operative

Article highlights

• Subcutaneous defibrillator (S-ICD) is the latest addition in the armamentarium for clinically available devices for the prevention of sudden cardiac death (SCD). Due to extravascular location and lack of transvenous leads, use of S-ICD is of particular advantage in patients at high risk of device infection.

• Appropriate patient selection using automated EKG screening tools is necessary prior to implantation of S-ICD. Appropriate screening minimizes the risk of inappropriate shocks from T-wave over sensing.

• Using pre-procedure marking to identify the landmarks may allow optimal S-ICD position and improve the success of defibrillation testing.

• Uninterrupted anticoagulation in the perioperative period may increase the risk of lateral pocket hematoma. If interruption of anticoagulation is not feasible from clinical standpoint, adequate hemostasis should be achieved in the device pocket.

• In the contemporary experience, monitored anesthesia care (MAC) is used as the preferred mode of anesthesia for implantation of S-ICD. MAC appears to result in decreased incidence of airway-associated complications and hemodynamic compromise due to general anesthesia. Moreover, MAC may allow early discharge for these patients.

• Intermuscular implantation of the S-ICD generator between the latissimus dorsi and serratus anterior muscles using 2-incision approach appears to be the preferred approach in the contemporary experience. Intermuscular device pocket allows a more posterior position of the pulse generator and ensures higher defibrillation success at the initial implantation.

• Although previous studies have shown a higher incidence of defibrillation failure in patients with high body mass index (BMI), recent data suggest that optimal system position mitigates unsuccessful defibrillation in these patients.

• Device site pain early after the S-ICD implantation is common. Preoperative use of oral analgesic medications and limited postoperative use of narcotic medications can allow optimal perioperative pain management on an outpatient basis.

• Implantation of S-ICD in patients with previous history of sternotomy or presence of left ventricular assist devices (LVAD) appears to be feasible. The risk of electromagnetic interference due to concomitant presence of S-ICD and LVAD or other cardiac implantable electronic devices appears to be minimal and can be further reduced by reprogramming the sensing vector.

• Post-implant exercise EKG testing to assess the risk of T-wave over sensing is not a routine clinical practice and has not been shown to be beneficial.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they receive consulting fees from Boston Scientific. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.