Implantable cardioverter-defibrillator: another device to cover

The implantable cardioverter-defibrillator is a mechanical device developed to manage patients with life-threatening arrhythmias when pharmacologic control has failed or produced unacceptable side effects. It is a significant amount of foreign material with a generator pack (volume 113 to 145 cc, weight 197 to 235 gm) and two or three leads and patches that are inserted into or placed on the heart. Although it has worked very well in preventing premature death, there have been complications associated with the device itself. The most significant of these has been exposure and/or infection. We present three patients who have experienced this problem. Improved coverage has been accomplished by burying the implant beneath the rectus abdominis muscle in situations where skin and subcutaneous tissue alone have proved inadequate. By dividing one or two tendinous inscriptions and the anterior limb of the internal oblique fascia, a musculofascial pocket is created to contain the generator and lead wires. This provided satisfactory coverage in two of our three patients. The single failure resulted from external trauma to the abdominal wall.