title: Intermuscular technique for implantation of the subcutaneous implantable cardioverter defibrillator: long-term performance and complications.
abstract: OBJECTIVE
  The subcutaneous cardioverter defibrillator was designed to overcome electrode complications of transvenous defibrillation systems. While largely achieved, pocket complications have increased. Subcutaneous implantation of the pulse generator leaves it prone to erosion, extrusion, discomfort, and poor cosmesis.
  
  
  RESULTS
  We use a demonstration electrode and pulse generator with fluoroscopy, prior to prepping and draping, to maximize the left ventricular mass between them. We adapted a submuscular abdominal ICD technique to implant the S-ICD intermuscularly between the anterior surface of serratus anterior and the posterior surface of latissimus dorsi. Surgery in our patients beyond the subcutaneous tissue was bloodless, as muscle layers were carefully separated but not incised, which also protected the long thoracic nerve. Two layers of muscle protect the pulse generator. We have implanted 82 consecutive patients with this technique, taking ∼65 min. All patients were converted with 65 J standard polarity shock during induced arrhythmia conversion testing, with six (7.3%) patients requiring a repositioning of the pulse generator prior to successful conversion. Seven spontaneous episodes of ventricular fibrillation were detected in three (3.6%) patients, all successfully converted back to sinus rhythm. Long-term patient outcomes have been good with low complication rates over the mean ± standard deviation 3.6 ± 1.2 years.
  
  
  CONCLUSIONS
  Our intermuscular technique and implant methodology is successful for placement of the subcutaneous defibrillator pulse generator. Our technique leads to an excellent cosmetic result and high levels of patient satisfaction. Rates of first shock conversion during defibrillation testing, inappropriate shocks, and complications during follow-up compare favourably with previous published case series. There were no left arm movement limitations post-operatively.
authors.affiliation: Division of Cardiac Surgery, University of Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany.
authors.forename: Joachim
authors.initials: J
authors.lastname: Winter
authors.affiliation: Division of Cardiology, Pulmonology and Vascular Medicine, University of Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Siekiera
authors.affiliation: Division of Cardiology, Pulmonology and Vascular Medicine, University of Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany.
authors.forename: Dong-In
authors.initials: DI
authors.lastname: Shin
authors.affiliation: Division of Cardiology, Pulmonology and Vascular Medicine, University of Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Meyer
authors.affiliation: Department of Diagnostic and Interventional Radiology, University of Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany.
authors.forename: Patric
authors.initials: P
authors.lastname: Kröpil
authors.affiliation: Institute for Anatomy II Medical Faculty, University of Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany.
authors.forename: Harald
authors.initials: H
authors.lastname: Clahsen
authors.affiliation: City University London, Northampton Sq., London, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: O'Connor
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001145:Arrhythmias, Cardiac / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D017147:Defibrillators, Implantable; D004554:Electric Countershock / Q000009:adverse effects / Q000295:instrumentation*; D004562:Electrocardiography; D005260:Female; D006801:Humans; D064169:Intermediate Back Muscles / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D011446:Prospective Studies; D011474:Prosthesis Design; D011475:Prosthesis Failure; D019919:Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D064171:Superficial Back Muscles / Q000000981:diagnostic imaging / Q000601:surgery*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult
keywords: Complications; Human; Intermuscular pulse generator implant; Subcutaneous implantable cardioverter-defibrillator