ELECTROPHYSIOLOGICAL LABORATORY, ELECTROPHYSIOLOGIST-IMPLANTED, NONTHORACOTOMY-IMPLANTABLE CARDIOVERTER DEFIBRILLATORS/

Background Implantable cardioverter/defibrillators (ICDs) have convent ionally been implanted in the operating room by surgeons. However, tec hnological developments have reduced size and increased Simplicity, br inging the procedure into the realm of the electrophysiologist. The pu rpose of this study was to evaluate the safety and efficacy of implant ation of the entire ICD system by electrophysiologists in an electroph ysiology laboratory. Methods and Results Between July 1993 and Februar y 1994, 23 patients (21 men; age, 64+/-11 years) underwent transvenous ICD implantation by electrophysiologists working alone, entirely in t he electrophysiology laboratory. Indications for ICD were sudden death in 10 patients, uncontrolled life-threatening ventricular tachycardia in 12, and syncope with cardiomyopathy and familial sudden death in 1 . Seventeen patients had coronary artery disease an a past history of acute myocardial infarction. Four patients had idiopathic dilated card iomyopathy, 1 had coronary ectasia and poor left ventricular function, and another had poor left ventricular function related to valvular dy sfunction. The mean left ventricular ejection fraction was 34+/-10% (r ange, 20% to 50%). General anesthesia was administered in 22 cases, an d deep sedation was used in 1 elderly patient. After positioning of tr ansvenous leads and subcutaneous patch/array lead positioning, defibri llation testing was performed. After transvenous and subcutaneous lead tunneling, all generators were placed subcutaneously in an abdominal pocket. The mean total time in the electrophysiology laboratory was 25 4+/-68 minutes (range, 150 to 375 minutes), with 104+/-42 minutes for anesthetic and other preparation, 159+/-45 minutes for implantation, a nd 8.7+/-5 minutes (range, 3 to 25 minutes) of fluoroscopy required fo r positioning of transvenous and subcutaneous lead systems. Implant ti mes showed a significant improvement when the first 10 cases (188+/-44 minutes) were compared with the last 10 in the series. (124+/-44 minu tes, P<.01). The mean defibrillation threshold was 17+/-5 J (range, 5 to 25 J). There were 5 complications (22%): 1 patch-site hematoma, 1 p neumothorax related to subclavian venous puncture, 1 pulmonary embolis m, and 2 patients requiring overnight ventilation after hemodynamic de terioration following defibrillation testing. There were no deaths, an d there were no infections. The mean time to hospital discharge after the implant was 5.1+/-3.5 days. After 11.6+/-9 weeks of follow-up, all devices were functioning satisfactorily, all patients had successfull y defibrillated at postimplant predischarge checkup with 29+/-5 J, and there had been no late complications. Conclusions This is the first r eport to show that nonthoracotomy ICD implantation may be successfully carried out by electrophysiologists working alone in the electrophysi ology laboratory, with a high rate of success and few complications, e ven in high-risk patients. This high rate of success and safety probab ly relates to the availability of high-quality fluoroscopy and familia rity with electrophysiology laboratory equipment and personnel.