European Journal of Cardio-Thoracic Surgery, Vol 8, 628-634, Copyright © 1994 by European Association for Cardio-thoracic Surgery
The implantable cardioverter defibrillator: the end of the thoracotomy approach
F Wellens, P Brugada, G Guiraudon, Y De Grieck, R De Geest and H Vanermen
Cardiovascular Center, OLV Hospital, Aalst, Belgium.
Internal cardioverter defibrillator (ICD) implantation has become a
standard therapy for life-threatening arrhythmias. A simple and safe
surgical implantation technique is therefore mandatory in this high risk
population. In a 30-month period 86 patients received 87 ICD devices. An
endocavitary lead system was used as first choice in 62 patients and
defibrillation thresholds (DFT) of 25 joules (J) or less were obtained in
57 patients. A thoracotomy approach was avoided using a biphasic shock wave
form in 17 patients and the addition of a subcutaneous (sc) patch in 11
patients or wire array lead in 9 patients. There was one early
non-technique related death (1.7%) after the transvenous approach.
Reoperation was necessary in three patients with lead complications and in
two patients for local device problems (one migration, one infection). With
the recent progress in ICD technology, a thoracotomy approach could be
avoided for the last 52 patients. For comfort and cosmetic reasons left
subcostal insertion of the device has been successfully used in the last 50
patients. We conclude that the nonthoracotomy approach can now be offered
to all patients in need for an ICD as a consequence of the technological
progress made in the field of electric treatment of malignant ventricular
arrhythmias. A stepwise approach with a minimum of implanted hardware and
the use of biphasic shock systems now offers a simple and efficient
treatment alternative with very low perioperative risk. Internal
cardioverter defibrillator implantation in combination with open heart
procedures can easily be avoided.
