Single- versus Dual-Coil ICD Leads: Does it Matter?

Transcription

1 Single- versus Dual-Coil ICD Leads: Does it Matter? C. W. Israel, M.D. Dept. of Cardiology Evangelical Hospital Bielefeld Germany

2 Conflict of Interest Biotronik Boston-Scientific Medtronic Sorin St. Jude Medical - participation in sponsored studies - speaker s honoraria - participation in sponsored studies - speaker s honoraria - participation in sponsored studies - speaker s honoraria - member of the advisory board - member of the advisory board - participation in sponsored studies - speaker s honoraria

3 Epicardial ICD Patches

4 Unipolar, Bipolar, and Triad System Critical mass theory: Successful defibrillation requires a minimum potential gradient of 6-7 V/cm within 90% of the heart for Defibrillation

5 Single- versus Dual-Coil ICD Leads 1. VF defibrillation success 2. VF defibrillation success: Special situations 3. AF defibrillation success 4. Lead complications 5. Extractability

6 Unipolar versus Triad System for Defibrillation Bardy, Circulation 1994;89:1090-3

7 Unipolar versus Triad System for Defibrillation Bardy, Circulation 1994;89:1090-3

8 Unipolar versus Triad System for Defibrillation 98% vs. 88% of pts had DFT 15 J with dual- vs. single-coil lead (p=0.05) shock impedance (p<0.001) decreased with dual-coil configuration Gold, J Am Coll Cardiol 1998;31:1391 4

9 Impact of the Position of SVC Coil N = 27, cross-over 96% vs. 81% of pts had DFT 15 J with SVC coil (either position) vs. single coil Gold, J Cardiovasc Electrophys 2000;11:25-9

10 Unipolar versus Triad System for Defibrillation 76 pts with standard ICD indication : dual-coil ICD lead (group 1): Endotak Reliance 0147/0148/ 0149 (Guidant) versus single-coil ICD lead (group 2): Endotak Reliance S 0127/0128/ 0129 (Guidant) no difference in DFTs Rinaldi, PACE 2003;26:

11 Unipolar versus Triad System for Defibrillation DFT and defibrillation resistance Group A: 62 patients with dual-coil ICD lead Group B: 76 patients with single-coil ICD lead Odds ratio of high DFT ( 15 J) the risk of high ( 15 J) DFT was 3x lower in patients with dual- than in patients with single-coil defibrillation lead DFT reduction of 14% 3fold reduction in risk of high DFT ( 15 J) Lubinski, Kardiol Pol 2005;63:234-41

12 Single- versus Dual-Coil ICD Leads 1. VF defibrillation success 2. VF defibrillation success: Special situations 3. AF defibrillation success 4. Lead complications 5. Extractability

13 Right-Sided ICD Implantation DFTs Epstein, J Cardiovasc Electrophys 1995;6:

14 Right-Sided ICD Implant retrospective analysis, 271 left- and 19 right-sided systems mean DFT in left-sided systems 11.3 ± 5.3 J compared to 17.0 ± 4.9 J for rightsided implantation (p < 0,0001) active can on right side decreased DFT (15 ± 4.1 J vs. 19 ± 4.8 J, p = 0.05) Friedman, PACE 1999;22:

15 Right-Sided ICD Implant Right-sided implants (n = 25) : hot versus cold can Kirk, Am J Cardiol 2001;88: right pectoral active can: no sign. effect on DFT varying effect in individual patients left pectoral active can: consistently lower DFT active cans improve defibrillation efficacy both by reducing shock impedance and by improving the current vector right-sided implant: better dual-coil available

16 Obesity and Emphysema

17 Pneumothorax Cohen, PACE 1998: 21: Schuchert, PACE 1998; 21:471-3

18 ICD Lead Placement in the RVOT Crossley, PACE 2009;32:166-71

19 Single- versus Dual-Coil ICD Leads 1. VF defibrillation success 2. VF defibrillation success: Special situations 3. AF defibrillation success 4. Lead complications 5. Extractability

20 Cardioversion of AF n = 58 atrial DFT for AF 4.7 vs J for dualvs. single-coil minor influence of triad shock vector Rashba, J Cardiovasc Electrophysiol 2004;15:790-4

21 Cardioversion of AF Single-coil Dual-coil, cold can Dual-coil, hot can shock impedance always lower with dual-coil/triad configuration than single coil difference particularly important in low shock energy Olsovsky, PACE 1999;22:165-8

22 Single- versus Dual-Coil ICD Leads 1. VF defibrillation success 2. VF defibrillation success: Special situations 3. AF defibrillation success 4. Lead complications 5. Extractability

23 Dual-Coil ICD Lead IS-1 BI Compact, strainrelieved trifurcation polyurethane overlay 8 cm SVC coil length DF-1 18 cm 8.6 Fr lead body 12 mm 8 mm 5.7 cm RV coil length Steroid-eluting tip electrode

24 Components of a Modern ICD Lead

25 ICD Lead Malfunction 1317 consecutive pts, ICD implanted at 3 European centers pts with lead malfunction requiring surgical revision (median FU 6.4 yrs), 5-year incidence of lead failure 2.5% Eckstein, Circulation 2008;117;

26 Single- versus Dual-Coil ICD Leads 1. VF defibrillation success 2. VF defibrillation success: Special situations 3. AF defibrillation success 4. Lead complications 5. Extractability

27 Isodiametric Design SVC coil PU Coating

28 Silicone Backfill and PTFE Coating Medtronic Sprint Guidant Reliance G

29 Flat Wire St. Jude Medical Durata lead Conventional round wire lead

30 Dual-Coil Lead Extraction Di Cori, PACE 2010;33;

31 Sprint Fidelis Extraction Reasons for extraction of 349 leads Periprocedural complications 349 leads extracted in 348 ICD patients average duration between implantation and extraction 27.5 months (0.03 to 58.8 months) all leads successfully extracted no periprocedural mortality no major complications Maytin, J Am Coll Cardiol 2010;56:646 50

32 Single- versus Dual-Coil ICD Leads: Does it Matter? defibrillation (general) dual-coil leads (+) defibrillation in high DFT dual-coil leads + defibrillation in RVOT leads dual-coil leads (+) defibrillation from right side dual-coil leads + cardioversion of AF dual-coil leads + obesity/emphysema dual-coil leads + lead complications single-coil leads (+) lead extraction single-coil leads (+)

33 Thank you very much for your attention!