THE IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR - THE END OF THE THORACOTOMY APPROACH

Internal cardioverter defibrillator (ICD) implantation has become a st andard therapy for life-threatening arrhythmias. A simple and safe sur gical implantation technique is therefore mandatory in this high risk population. In a 30-month period 86 patients received 87 ICD devices. An endocavitary lead system was used as first choice in 62 patients an d defibrillation thresholds (DFT) of 25 joules (J) or less were obtain ed in 57 patients. A thoracotomy approach was avoided using a biphasic shock wave form in 17 patients and the addition of a subcutaneous (sc ) patch in 11 patients or wire array lead in 9 patients. There was one early non-technique related death (1.7%) after the transvenous approa ch. Reoperation was necessary in three patients with lead complication s and in two patients for local device problems (one migration, one in fection). With the recent progress in ICD technology, a thoracotomy ap proach could be avoided for the last 52 patients. For comfort and cosm etic reasons left subcostal insertion of the device has been successfu lly used in the last 50 patients. We conclude that the non-thoracotomy approach can now be offered to all patients in need for an ICD as a c onsequence of the technological progress made in the field of electric treatment of malignant ventricular arrhythmias. A stepwise approach w ith a minimum of implanted hardware and the use of biphasic shock syst ems now offers a simple and efficient treatment alternative with very low perioperative risk. Internal cardioverter defibrillator implantati on in combination with open heart procedures can easily be avoided.