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 control. A left subcostal incision extended to the left pleural cavity was performed. Using thoracoscopy the patch was positioned on the pericardium, suture d and connected to the defibrillator. DTs were 10, 10 and 20 J respect ively in our 3 patients. Postoperative course was uneventful. Thoracos copy allows other techniques such as a stellectomy, which we performed in a 33 year old woman with long QT syndrome. Patients were reassesse d after 8 days and 2 months. Termination of induced ventricular fibril lation was achieved with the same minimal energy levels used peroperat ively. In conclusion, extrapericardial patch insertion using thoracosc opy may help reduce DT in ICD patients with a non thoracotomy lead sys tem. Comparison with other lead configurations requires further invest igation.