Thoracoscopic approach to implantable cardioverter defibrillator patch electrode implantation

Even if transvenous lead system for automatic implantable cardioverter defibrillators (ICDs) has been one of the main surgical advances in the recent past, its major limitation is the high defibrillation thresholds in some cases. Thus, an additional patch may be required and implanted either in a subcutaneous position or in an epicardial position. We describe another possibility: the implantation of extrapericardial patch under video-thoracoscopic control. This new technique allows a deep implantation of the whole material without thoracotomy. Seven patients were included in our preliminary experience. During defibrillation threshold evaluation, two patients required 34 J with the single transvenous lead system, and five patients were not defibrillated with the single lead system; therefore, they required a 300-J external rescue shock. We decided to implant an additional patch in those seven patients with high defibrillation thresholds. This patch was inserted into the pleural cavity through a left subcostal incision. Under video thoracoscopy, it was positioned and stitched onto the pericardium. The defibrillation generator was then implanted through the left subcostal incision in a subdiaphragmatic space. As a result, preoperative defibrillation thresholds were significantly reduced (14.29 +/- 3.45 J, mean +/- SD) and remained stable during follow-up controls (eighth day and second month). Long-term follow-up (14 +/- 4.5 months) was uneventful, with an excellent tolerance for the patients. In conclusion, extrapericardial implantation of defibrillation patches under video thoracoscopy is an easy technique that allows low defibrillation thresholds.