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Francis Fynn-Thompson, M.D.1, Frank Cecchin, M.D.2.
1Cardiac Surgery, Children's Hospital Boston, Boston, MA, USA, 2Cardiology, Children's Hospital Boston, Boston, MA, USA.
Objective: In pediatric patients, transvenous ICD implantation may be limited by patient size, venous, or cardiac anatomy. We have developed an innovative minimally invasive approach to placement of an effective ICD configuration without a transvenous shocking coil, epicardial patches or subcutaneous arrays in infants and small children.
Methods: Retrospective review of minimally invasive ICD implantation in 6 pediatric patients between 2004 and 2006. The indications for ICD placement were malignant ventricular rhythms and long QT syndrome. The operative approach was via a subxiphoid incision and placement of epicardial dual chamber pace/sense leads and a transvenous design ICD lead in the posterior pericardium. The lowest energy tested in the operating room was used as a surrogate for defibrillation threshold (DFT).
Results: 6 patients underwent implant at a mean age of 2.4 years (range: 0.5-4.4), with a mean weight of 14.9 kg (range: 5.2-20.4). The mean lowest energy required for defibrillation was 8J (range: 3-11). One patient underwent a concomitant thoracoscopic sympathectomy. The diagnosis included idiopathic ventricular arrhythmias and long QT syndrome. There were no procedural related complications. All patients were extubated immediately after the procedure and were discharged from the intensive care unit within 24hrs.
Conclusion: ICD implantation can be performed in infants and small children effectively using an innovative minimally invasive technique. This allows ICD use in patients deemed too small for conventional transvenous ICD leads and avoids the use of epicardial patches and subcutaneous arrays. The long-term outcome and possible complications are yet unknown and close follow up is required to assess DFTs. 
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