Intermuscular technique for implantation of the subcutaneous implantable cardioverter defibrillator: long-term performance and complications

TY - JOUR

T1 - Intermuscular technique for implantation of the subcutaneous implantable cardioverter defibrillator: long-term performance and complications

AU - Winter, Joachim

AU - Siekiera, Markus

AU - Shin, Dong-In

AU - Meyer, Christian

AU - Kröpil, Patric

AU - Clahsen, Harald

AU - O'Connor, Stephen

N1 - Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

PY - 2017/12/1

Y1 - 2017/12/1

N2 - Aims: The subcutaneous cardioverter defibrillator was designed to overcome electrode complications of transvenous defibrillation systems. While largely achieved, pocket complications have increased. Subcutaneous implantation of the pulse generator leaves it prone to erosion, extrusion, discomfort, and poor cosmesis.Methods and results: We use a demonstration electrode and pulse generator with fluoroscopy, prior to prepping and draping, to maximize the left ventricular mass between them. We adapted a submuscular abdominal ICD technique to implant the S-ICD intermuscularly between the anterior surface of serratus anterior and the posterior surface of latissimus dorsi. Surgery in our patients beyond the subcutaneous tissue was bloodless, as muscle layers were carefully separated but not incised, which also protected the long thoracic nerve. Two layers of muscle protect the pulse generator. We have implanted 82 consecutive patients with this technique, taking ∼65 min. All patients were converted with 65 J standard polarity shock during induced arrhythmia conversion testing, with six (7.3%) patients requiring a repositioning of the pulse generator prior to successful conversion. Seven spontaneous episodes of ventricular fibrillation were detected in three (3.6%) patients, all successfully converted back to sinus rhythm. Long-term patient outcomes have been good with low complication rates over the mean ± standard deviation 3.6 ± 1.2 years.Conclusion: Our intermuscular technique and implant methodology is successful for placement of the subcutaneous defibrillator pulse generator. Our technique leads to an excellent cosmetic result and high levels of patient satisfaction. Rates of first shock conversion during defibrillation testing, inappropriate shocks, and complications during follow-up compare favourably with previous published case series. There were no left arm movement limitations post-operatively.

AB - Aims: The subcutaneous cardioverter defibrillator was designed to overcome electrode complications of transvenous defibrillation systems. While largely achieved, pocket complications have increased. Subcutaneous implantation of the pulse generator leaves it prone to erosion, extrusion, discomfort, and poor cosmesis.Methods and results: We use a demonstration electrode and pulse generator with fluoroscopy, prior to prepping and draping, to maximize the left ventricular mass between them. We adapted a submuscular abdominal ICD technique to implant the S-ICD intermuscularly between the anterior surface of serratus anterior and the posterior surface of latissimus dorsi. Surgery in our patients beyond the subcutaneous tissue was bloodless, as muscle layers were carefully separated but not incised, which also protected the long thoracic nerve. Two layers of muscle protect the pulse generator. We have implanted 82 consecutive patients with this technique, taking ∼65 min. All patients were converted with 65 J standard polarity shock during induced arrhythmia conversion testing, with six (7.3%) patients requiring a repositioning of the pulse generator prior to successful conversion. Seven spontaneous episodes of ventricular fibrillation were detected in three (3.6%) patients, all successfully converted back to sinus rhythm. Long-term patient outcomes have been good with low complication rates over the mean ± standard deviation 3.6 ± 1.2 years.Conclusion: Our intermuscular technique and implant methodology is successful for placement of the subcutaneous defibrillator pulse generator. Our technique leads to an excellent cosmetic result and high levels of patient satisfaction. Rates of first shock conversion during defibrillation testing, inappropriate shocks, and complications during follow-up compare favourably with previous published case series. There were no left arm movement limitations post-operatively.

KW - Adolescent

KW - Adult

KW - Aged

KW - Aged, 80 and over

KW - Arrhythmias, Cardiac/diagnosis

KW - Defibrillators, Implantable

KW - Electric Countershock/adverse effects

KW - Electrocardiography

KW - Female

KW - Humans

KW - Intermediate Back Muscles/diagnostic imaging

KW - Male

KW - Middle Aged

KW - Patient Satisfaction

KW - Prospective Studies

KW - Prosthesis Design

KW - Prosthesis Failure

KW - Prosthesis Implantation/adverse effects

KW - Superficial Back Muscles/diagnostic imaging

KW - Time Factors

KW - Tomography, X-Ray Computed

KW - Treatment Outcome

KW - Young Adult

U2 - 10.1093/europace/euw297

DO - 10.1093/europace/euw297

M3 - SCORING: Journal article

C2 - 28007749

VL - 19

SP - 2036

EP - 2041

JO - EUROPACE

JF - EUROPACE

SN - 1099-5129

IS - 12

ER -