Subxiphoid approach for insertion of ICDs after previous median sternotomy

To avoid the risks both of repeat median sternotomy and of thoracotomy, the modified subxiphoid approach was adopted for insertion of implantable cardioverter-defibrillators in 10 patients who had previously undergone cardiac operations via median sternotomy. Effective implantable cardioverter-defibrillator systems were implanted in all patients. There were no operative deaths and no hemorrhagic or respiratory complications. One patient underwent repositioning of a dislodged superior vena caval electrode, and an infected generator pocket developed in 1 patient. Early extubation was routine. Two patients were observed in the coronary care unit for the first postoperative night. Postoperative pain was controlled with oral analgesic agents. The subxiphoid approach is safe and effective, and it carries a substantially lower risk of complications than other techniques, even in this high-risk group of patients. By minimizing the need for admission to the intensive care unit, invasive monitoring, and prolonged ventilatory support, by reducing surgical complications, and by shortening the hospital stay, the subxiphoid approach saved an average of $3,295 per patient.