ONE-INCISION APPROACH FOR INSERTION OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS

The placement of a transvenous implantable cardioverter defibrillator (ICD) system through a single infraclavicular skin incision has been a surgical goal for years. The development of a new investigational mod el of ICD with substantially reduced dimensions (volume, 83 cm(3); mas s, 132 g) has made the one-incision approach a clinical reality. Betwe en March and September 1993, 4 female and 19 male patients (mean age, 60 +/- 9.6 years; range, 46 to 73 years) underwent implantation of thi s device for the treatment of ventricular fibrillation (n = 14) or ven tricular tachycardia (n = 9). One transvenous lead was placed in the r ight ventricular apex and another in the left subclavian vein. A subpe ctoral pocket was formed in the infraclavicular area from the same inc ision to house the ICD generator and, if necessary, the subcutaneous p atch. The mean operation time (81.5 +/- 32.7 minutes; range, 54 to 195 minutes) was significantly shorter than that noted for a previous ser ies made up of patients undergoing traditional transvenous ICD implant ations. In 20 patients (87%), endovenous defibrillation without a subc utaneous patch successfully caused externally induced ventricular fibr illation to revert with a mean minimum energy output of 21.9 +/- 3.5 J (range, 12 to 24 J). Endovenous defibrillation was more successful wh en biphasic (n = 16/17 [94%]) shocks rather than monophasic shocks (n = 4/6 [67%]) were used. No mortality, morbidity, or surgical complicat ions were observed. These results indicate that the one-incision appro ach and the small size of the ICD generator can substantially facilita te ICD implantation and result in a reduction in the surgical trauma, the operation time, and the amount of material implanted.