IMPLANTATION BY ELECTROPHYSIOLOGISTS OF 100 CONSECUTIVE CARDIOVERTER-DEFIBRILLATORS WITH NONTHORACOTOMY LEAD SYSTEMS

Background Traditional lead systems for implantable cardioverter defib rillators (ICDs) require a thoracotomy for placement. Nonthoracotomy l ead systems are available and are usually implanted by an electrophysi ologist and a surgeon. The purpose of this study was to prospectively evaluate the safety and efficacy of ICD implantation with a nonthoraco tomy lead system by electrophysiologists. Methods and Results A consec utive series of 100 patients (mean age, 61+/-13 years, +/-SD) underwen t ICD implantation with a nonthoracotomy lead system while intubated a nd under general anesthesia. Seventy-seven patients had coronary arter y disease, 15 had idiopathic cardiomyopathy, 6 had miscellaneous heart disease, and 2 had structurally normal hearts. The mean ejection frac tion was 0.29+/-0.13. Sixty-eight patients had suffered a cardiac arre st, and 32 had had ventricular tachycardia or syncope. All patients ex cept 9 underwent electrophysiological testing and had failed 1+/-1 dru g trials before ICD implantation. Three types of nonthoracotomy lead s ystems were used. The nonthoracotomy lead with an ICD was successfully implanted in 96 patients (96%). Of the unsuccessful implants, 1 patie nt did not have venous access, the passive fixation lead in 1 would no t remain lodged, 1 had elevated defibrillation thresholds, and 1 devel oped a hemopneumothorax while venous access was being obtained. The me an defibrillation threshold was 17+/-6 J. The mean procedure duration was 161+/-57 minutes. When a subcutaneous patch was used (n=58), the p rocedure duration was 189+/-5 minutes, and when a subcutaneous patch w as not required (n=40), the procedure lasted 123+/-37 minutes (P<.0001 ). Patients remained in the hospital 4.5+/-4.1 days after implantation , with no procedure-related deaths. Acute complications occurred in 10 patients; 2 had lead dislodgments, 1 with previous abdominal surgery had his abdominal cavity entered (without other complications) while t he ICD pocket was being made, 1 had postoperative heart failure, 1 dev eloped a large hematoma when anticoagulation therapy was initiated, 3 required reintubation because of excessive anesthesia, 1 developed sup erficial cellulitis, and 1 developed a hemopneumothorax secondary to a lacerated subclavian vein. During 6+/-3 months of follow-up, 2 patien ts developed lead fractures. Conclusions (1) Electrophysiologists can implant an ICD with a nonthoracotomy lead system safely and with a hig h success rate; (2) use of a subcutaneous patch correlates with longer procedure durations; and (3) special precautions should be taken in p atients with previous abdominal surgery.