Subpectoral cardioverter-defibrillator implantation using a lateral approach

Third-generation cardioverter-defibrillators have revolutionized management of ventricular tachyarrhythmias. Implantation can be performed in the electro-physiology laboratory, with minimal morbidity. Generator size has shrunk to the point that subcutaneous implantation is feasible and safe, even under local anesthesia. The prepectoral technique, however, is associated with increased mechanical stress to the subcutaneous tissue and can predispose to device erosion or infection. These complications may be avoided by submuscular placement. Among subpectoral techniques, the lateral approach offers unrestricted ability to deploy patches or array electrodes, should the need arise, and may represent the optimal implant technique under some circumstances.

We studied 29 male patients, aged 29-78 years, who presented with syncope or sustained ventricular tachycardia, and underwent subpectoral defibrillator implantation under general anesthesia or conscious sedation. All devices were third-generation active can systems with biphasic shock capability. Six dual-chamber defibrillators were used.

Subpectoral implantation was successful in all cases, with an estimated blood loss of 28+/-17 mL and no immediate complications. Except for one patient who developed twiddler's syndrome and ultimately required revision to a subcutaneous pocket, the implant site was tolerated well, and no limitation in the range of motion of the upper limb was observed during 20 months of follow-up.

Subpectoral implantation using a lateral approach is technically straightforward and can be applied globally, with modest additional resource and equipment requirements. Familiarity with this approach can maximize the likelihood of successful defibrillator implantation in the electrophysiology laboratory.