Pectoral cardioverter defibrillators: Comparison of prepectoral and submuscular implantation techniques

The purpose of this study was to compare the two techniques of pectoral ICD implantation, prepectoral and submuscular, performed by an electrophysiolo gist in the catheterization laboratory with use of general or local anesthe sia in 45 consecutive patients. Over a period of 30 months, we implanted pe ctoral transvenous ICDs in 43 men and 2 women, aged 59 +/- 12 years, with u se of general (n = 20) or local (n = 25) anesthesia in the catheterization laboratory. Patients had coronary (n = 30) or valvular (n = 4) disease, car diomyopathy (n = 20) or no organic disease (n = 1), a mean left ventricular election fraction of 31%, and presented with ventricular tachycardia (n = 40) or fibrillation (n = 5). One-lead ICD systems (18 Endotak, 20 Transvene /8 Sprint, 2 EnGuard) were used in 38 patients, 2-lead (5 Transvene, 1 EnGu ard) systems in 6 patients, and 2 atrioventricular lead ICD system in 1 pat ient. The prepectoral technique was employed in 29 patients with adequate s ubcutaneous tissue, while the sub-muscular technique was used in 2 6 patien ts who had a thin layer of subcutaneous tissue. The defibrillation threshol d averaged 9-10 J in both groups and there were no differences in pace/sens e thresholds. All implants were entirely transvenous with no subcutaneous p atch. Biphasic ICD devices were employed in all patients. Active or hot can devices were used in 39 patients. There were no complications, operative d eaths, or infections; Patients were discharged at a mean of 3 days. All dev ices functioned well at predischarge testing. Over 14 +/- 8 months, 20 pati ents received appropriate device therapy (antitachycardia pacing or shocks) . No late complications occurred. One patient died at 3 months of pump fail ure; there were no sudden deaths. In conclusion, for exclusive pectoral imp lantation of transvenous ICDs, electrophysiologists should master both prep ectoral and submuscular techniques. One can thus avoid potential skin erosi on or need for abdominal implantation in patients with a thin layer of subc utaneous tissue. Finally, there are no differences in pacing or defibrillat ion thresholds between the two techniques.