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Ann Thorac Surg 1989;48:371-375
© 1989 The Society of Thoracic Surgeons

Articles

Transdiaphragmatic Implantation of the Automatic Implantable Cardioverter Defibrillator

Nadiv Shapira, MD*, Andrew I. Cohen, MD, Marc Wish, MD, Lawrence J. Weston, MD, Ross D. Fletcher, MD

Veterans Administration, Walter Reed Army and Georgetown University Medical Centers, Washington, DC

Accepted for publication April 17, 1989.

* Address reprint requests to Dr Shapira, Department of Cardiovascular Surgery, The Medical Center of Delaware, 4745 Stanton-Ogletown Rd, Suite 205, Newark, DE 19713-2070

A new surgical approach for implantation of the automatic implantable cardioverter defibrillator without thoractomy was used in 12 patients, aged 46 to 72 years. Preimplantation arrhythmia was ventricular tachycardia in 7 patients and ventricular fibrillation in 5 patients. The mean ejection fraction was 19%. Six patients were at high risk for general anesthesia for a variety of medical problems, and 2 patients had had a previous cardiac operation. Epidural anesthesia was used in 8 patients without intubation. The surgical approach used a longitudinal epigastric extraperitoneal incision with access to the heart through an incision made in the central tendon of the diaphragm. Two patches and two epicardial sensing leads were placed in all patients. All patients but one could be defibrillated with 20 J or less. There was no operative mortality and minimal morbidity. There were two late deaths due to heart failure. Thus, the transdiaphragmatic approach provides an excellent exposure for automatic implantable cardioverter defibrillator implantation, avoids general anesthesia and thoracotomy, and can be used after a previous cardiac operation.




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