PROSPECTIVE EVALUATION OF SHOULDER-RELATED PROBLEMS IN PATIENTS WITH PECTORAL CARDIOVERTER-DEFIBRILLATOR IMPLANTATION

Background The pectoral approach to implantation of cardioverter defib rillators (ICDs) has become a standard in defibrillator therapy becaus e of reduced generator size, weight, and volume. But the size of these devices is still comparable to the size of the early conventional ant ibradycardia pacemakers that were associated with a number of signific ant pocket-and shoulder-related problems after implantation in the pec toral region. In a prospective, single-center study of 50 patients wit h subpectoral implantation of a fourth-generation ICD, the ipsilateral shoulder joint was evaluated regarding active shoulder motility, shou lder-related pain, shoulder function, shoulder elevation, insertion te ndinitis, and morphologic alterations of the shoulder. Methods and Res ults The shoulder was evaluated before implantation and at 3, 6, and 1 2 months after implantation. Shoulder motility was documented by evalu ating active abduction, forward flexion, and external rotation. Should er-related pain and function were documented by the ''Basic Shoulder E valuation Form,'' insertion tendinitis was diagnosed by standardized p alpation and the impingment test, and morphologic alterations were doc umented by ultrasound and radiograph of the shoulder. Three months aft er implantation, 20 (40%) patients had a reduced active abduction, 30 (60%) patients had an impaired active forward flexion, and eight (16%) patients had a reduced external rotation. Thirty-one (62%) patients r eported shoulder-related pain or impaired shoulder function according to the ''Basic Shoulder Evaluation Form.'' Twenty-four (48%) patients showed a shoulder elevation and 21 (42%) patients demonstrated clinica l signs of insertion tendinitis. After 12 months the number of patient s with reduced active abduction, forward flexion, and external rotatio n dropped to four (8%). Shoulder-related pain and reduced function wer e documented in seven (13%) patients, four (8%) patients still had sho ulder elevation, and five (10%) patients still had signs of insertion tendinitis. None of the postoperatively performed ultrasounds or radio graphs showed any pathologic shoulder alterations. No predictors for t he occurrence of shoulder-associated problems could be found. Conclusi ons (1) Decreased active shoulder motility, shoulder-related pain, red uced function, shoulder elevation, and insertion tendinitis of the ips ilateral shoulder joint are diagnosed in many patients 3 months after subpectoral ICD implantation. (2) After 12 months the number of patien ts with impaired shoulder motility, function, shoulder-related pain, s houlder elevation, and insertion tendinitis decreased significantly. ( 3) Ultrasound and radiographs of the ipsilateral shoulder showed no ev idence of pathologic morphologic alterations after subpectoral ICD imp lantation. (4) No shoulder-associated problems required an operative r evision of the subpectoral generator pocket.