Subcutaneous Single-Incision Implantation of Cardioverter-Defibrillators Under Local Anesthesia by Electrophysiologists in the Electrophysiology Laboratory

Abstract

Implantable cardioverter-defibrillators (ICDs) have traditionally been implanted at the operating room under general anesthesia. Endocardial lead systems and downsized devices allowed implantation by electrophysiologists in the pectoral region. The present study evaluates the safety and efficacy of subcutaneous ICD implantation performed entirely by electrophysiologists using a single-incision approach for lead insertion and device placement under local anesthesia. Between June 1996 and May 1997, 51 of 52 consecutive patients (41 men and 10 women, mean age 58 ± 9 years) underwent ICD implantation at the electrophysiology laboratory. Local anesthesia and intravenous sedation were administered to all patients. After transvenous lead positioning by either venotomy of the left cephalic vein (n = 16) or puncture of the left subclavian vein (n = 35), all ICDs were implanted subcutaneously at the left subclavicular region. Fifty procedures (98%) were successful at first attempt. The mean implantation time was 76 ± 22 minutes and the mean fluoroscopy time was 7.5 ± 5.2 minutes. Patients received ICD devices generating biphasic waveforms. The mean defibrillation threshold was 11 ± 3 J. Procedure-related complications occurred in 5 patients (10%): 1 lead dislocation, 2 pocket hematomas, and 2 pneumothorax requiring drainage. Mean time from implantation to hospital discharge was 1.8 ± 1.2 days. During follow-up (38 ± 14 weeks), all devices were operating appropriately and no major complications occurred. In conclusion, this report demonstrates that a single-incision subcutaneous technique for ICD implantation can be safely and successfully performed by electrophysiologists using local anesthesia and intravenous sedation. The high success rate, low complication occurrence, and short implantation and fluoroscopy times make this cost-effective technique in the electrophysiology laboratory the method of choice.