NEW APPROACH TO IMPLANTATION OF AUTOMATIC DEFIBRILLATORS USING VIDEOTHORACOSCOPY

Nonthoracotomy lead systems are increasingly used in patients (pts) wi th implantable cardioverter defibrillator (ICD). In this setting, due to high energy requirements, a subcutaneous patch may be necessary in addition to endocardial leads. However in some patients, high defibril lation threshold (DT) may persist leading to thoracotomy for epicardia l patch placement. In a preliminary experience, 3 patients with high D T (> 20 J) following endocardial lead system, underwent the insertion of a extrapericardial patch under video-thoracoscopic central. A left subcostal incision extended to the left pleural cavity was performed. Using thoracescopy the patch was positioned on the pericardium, suture d and connected to the defibrillaor. DTs were 10, 10 and 20 J respecti vely in our 3 patients. Postoperative course was uneventful. Thoracosc opy allows other techniques such as a stellectomy, which we performed in a 33 year old woman with long QT syndrome. Patients were reassessed after 8 days and 2 months. Termination of induced ventricular fibrill ation was achieved with the same minimal energy levels used peroperati vely. In conclusion, extrapericardial patch insertion using thoracosco py may help reduce DT in ICD patients with a non thoracotomy lead syst em. Comparison with other lead configurations requires further investi gation.