[Implantation of automatic defibrillators by means of video-thoracoscopy. Authors' experience]

The implantable cardioverter-defibrillator represents an effective option for some potentially lethal ventricular arrhythmias. Nowadays defibrillation electrodes are often endoluminal only. In some patients, however, the presence of high defibrillation thresholds mandates the implantation of a subcutaneous patch. If the subcutaneous patch does not allow a sufficient decrease in defibrillation threshold, then two epicardial patches are generally implanted by different surgical approaches. Nevertheless surgical trauma could be a serious hazard in unstable patients. In 6 patients in whom endoluminal electrodes did not allow a safe defibrillation threshold, an extrapericardial patch has been implanted by means of a video-thoracoscopic approach: a left subcostal incision is performed and the subdiaphragmatic extraperitoneal space is reached; a patch electrode is then introduced into the left pleural cavity by blunt dissection of the diaphragm. This patch is positioned under thoracoscopic control in contact to the left pericardial surface and fixed by single stitches sutures. The impulse generator is finally implanted into the subdiaphragmatic pocket. In all the patients the patch electrode configuration sufficiently decreased defibrillation thresholds. In one of the patients a stellectomy was thoracoscopically performed to treat the long QT syndrome which was the cause of the ventricular fibrillation episodes. Defibrillation thresholds were confirmed after 8 day and 2 months postoperatively. In conclusion, the thoracoscopic implantation of an extrapericardial patch has allowed a significant reduction of defibrillation thresholds, without recurring to a major surgical procedure.