Key result
Epicardial ICDs show similar adjusted lead failure risk to transvenous systems in children.
Why the study?
ICD use is increasing in children, but controversy remains regarding epicardial versus transvenous approaches, with no specific recommendations.
Does an epicardial ICD approach alter the risk of ICD-related complications compared to a transvenous approach in pediatric patients?
Cohort (n=122)
No
Does an epicardial ICD approach alter the risk of ICD-related complications compared to a transvenous approach in pediatric patients?
In pediatric patients, the seemingly higher risk of lead dysfunction with epicardial ICDs compared to transvenous devices is largely driven by their preferential use in younger and smaller children.
Answers are grounded in this paper and cite their sources.
Early complications with epicardial ICDs in children are confounded by age and size; leaves open independent device effects on lead failure.
AIMS: The implantable cardioverter defibrillator (ICD) has been increasingly used in children. Both epicardial and transvenous approaches are used, with controversy regarding the best option with no specific recommendations. We aimed to compare outcomes associated with epicardial vs. transvenous ICDs in children. METHODS AND RESULTS: Data were analysed from a retrospective study including all patients <18-year-old implanted with an ICD in a tertiary centre from 2003 to 2021. Outcomes were compared between epicardial and transvenous ICDs. A total of 122 children with an ICD (mean age 11.5 ± 3.8 years, 57.4% males) were enrolled, with 84 (64.1%) epicardial ICDs and 38 (29.0%) transvenous ICDs. Early (<30 days) ICD-related complications were reported in 17 (20.2%) patients with an epicardial ICD vs. 0 (0.0%) with a transvenous ICD (P = 0.002). Over a mean follow-up of 4.8 ± 4.0 years, 25 (29.8%) patients with an epicardial ICD and 9 (23.7%) patients with a transvenous ICD experienced at least one late ICD-related complication [hazard ratio (HR) 1.8, 95% confidence interval (CI) 0.8-4.0]. Implantable cardioverter defibrillator lead dysfunction occurred in 19 (22.6%) patients with an epicardial ICD vs. 3 (7.9%) with a transvenous ICD (HR 5.7, 95% CI 1.3-24.5) and was associated with a higher incidence of ICD-related reintervention (HR 3.0, 95% CI 1.3-7.0). After considering potential confounders, especially age and weight at implantation, this association was no longer significant (P = 0.112). The freedom from ICD lead dysfunction was greater in patients with pleural coils than in those with epicardial coils (HR 0.38, 95% CI 0.15-0.96). CONCLUSION: In children, after a consideration of patient characteristics at implantation, the burden of complications and ICD lead dysfunction appears to be similar in patients with epicardial and transvenous devices. Pleural coils seem to be associated with better outcomes than epicardial coils in this population. CLINICAL TRIAL REGISTRATION: NCT05349162.
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Bos et al. (2023) conducted a cohort in Pediatric patients requiring an implantable cardioverter defibrillator (ICD) (n=122). Epicardial implantable cardioverter defibrillator vs. Transvenous implantable cardioverter defibrillator was evaluated on Late (>30 days) ICD-related complication (HR 1.8, 95% CI 0.8-4.0, p=0.153). Epicardial ICDs in children showed a higher unadjusted risk of early complications and lead dysfunction compared to transvenous ICDs, but the risk of lead failure was similar after adjusting for age and weight.
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