title: Implantation by electrophysiologists of 100 consecutive cardioverter defibrillators with nonthoracotomy lead systems.
abstract: BACKGROUND
  Traditional lead systems for implantable cardioverter defibrillators (ICDs) require a thoracotomy for placement. Nonthoracotomy lead systems are available and are usually implanted by an electrophysiologist and a surgeon. The purpose of this study was to prospectively evaluate the safety and efficacy of ICD implantation with a nonthoracotomy lead system by electrophysiologists.
  
  
  RESULTS
  A consecutive series of 100 patients (mean age, 61 +/- 13 years, +/- SD) underwent ICD implantation with a nonthoracotomy lead system while intubated and under general anesthesia. Seventy-seven patients had coronary artery disease, 15 had idiopathic cardiomyopathy, 6 had miscellaneous heart disease, and 2 had structurally normal hearts. The mean ejection fraction was 0.29 +/- 0.13. Sixty-eight patients had suffered a cardiac arrest, and 32 had had ventricular tachycardia or syncope. All patients except 9 underwent electrophysiological testing and had failed 1 +/- 1 drug trials before ICD implantation. Three types of nonthoracotomy lead systems were used. The nonthoracotomy lead with an ICD was successfully implanted in 96 patients (96%). Of the unsuccessful implants, 1 patient did not have venous access, the passive fixation lead in 1 would not remain lodged, 1 had elevated defibrillation thresholds, and 1 developed a hemopneumothorax while venous access was being obtained. The mean defibrillation threshold was 17 +/- 6 J. The mean procedure duration was 161 +/- 57 minutes. When a subcutaneous patch was used (n = 58), the procedure duration was 189 +/- 5 minutes, and when a subcutaneous patch was 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 the ICD pocket was being made, 1 had postoperative heart failure, 1 developed a large hematoma when anticoagulation therapy was initiated, 3 required reintubation because of excessive anesthesia, 1 developed superficial cellulitis, and 1 developed a hemopneumothorax secondary to a lacerated subclavian vein. During 6 +/- 3 months of follow-up, 2 patients developed lead fractures.
  
  
  CONCLUSIONS
  (1) Electrophysiologists can implant an ICD with a nonthoracotomy lead system safely and with a high success rate; (2) use of a subcutaneous patch correlates with longer procedure durations; and (3) special precautions should be taken in patients with previous abdominal surgery.
authors.affiliation: Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 18109-0022.
authors.forename: S A
authors.initials: SA
authors.lastname: Strickberger
authors.forename: J D
authors.initials: JD
authors.lastname: Hummel
authors.forename: E
authors.initials: E
authors.lastname: Daoud
authors.forename: M
authors.initials: M
authors.lastname: Niebauer
authors.forename: B D
authors.initials: BD
authors.lastname: Williamson
authors.forename: K C
authors.initials: KC
authors.lastname: Man
authors.forename: L
authors.initials: L
authors.lastname: Horwood
authors.forename: A
authors.initials: A
authors.lastname: Schmittou
authors.forename: S J
authors.initials: SJ
authors.lastname: Kalbfleisch
authors.forename: J J
authors.initials: JJ
authors.lastname: Langberg
mesh_terms: D000768:Anesthesia, General; D009202:Cardiomyopathies / Q000628:therapy; D003327:Coronary Disease / Q000628:therapy; D017147:Defibrillators, Implantable; D004567:Electrodes, Implanted; D004594:Electrophysiology; D004867:Equipment Design; D005069:Evaluation Studies as Topic; D005260:Female; D005500:Follow-Up Studies; D006323:Heart Arrest / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D017180:Tachycardia, Ventricular / Q000628:therapy; D013908:Thoracotomy; D013997:Time Factors