Bilateral Anterior Thoracotomy for Automatic Implantable Cardioverter Defibrillator Placement in Patients With Previous Sternotomy Shreekanth V. Karwande, MD, and John R. Rowles, MD Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Medical Center, Salt Lake City, Utah
Bilateral anterior thoracotomy, extrapericardial patches, and endocardial sensing lead placement have been used in 40 patients with previous sternotomy. The mean defibrillation threshold was 15 J, and in all patients the defibrillation threshold was less than 20 J. The surgical procedure is simplified with less risk by avoiding dissection of previously operated regions. Serious pulmonary
complications have been avoided by adequate pain control with epidural analgesia and early mobilization. This technique has successfully been used in patients with underlying chronic obstructive pulmonary disease and amiodarone-induced pulmonary fibrosis. All patients have been extubated by the first postoperative day. (Ann Thorac Surg 1992;54:791-3)
A
dure for postoperative analgesia. Perioperative prophylactic antibiotics are used in all patients. The patient is placed supine on the operating table and the skin is prepared from the chin to the iliac crests. A single-lumen endotracheal tube is used for general anesthesia. A small incision inferior to the left midclavicle is made, and a right ventricular endocardial sensing lead is placed through the left subclavian vein using a modified Seldinger technique with fluoroscopic guidance (Fig 1A). Two operating teams perform simultaneous bilateral anterior thoracotomies through the fifth intercostal space for extrapericardial patch lead placement (Figs lB, 1C). Dissection of extrapericardial fat is not done unless it is necessary for direct pericardial placement of anchoring sutures. A large patch lead is placed on the left ventricle around the apex and secured with four interrupted nonabsorbable sutures at each corner (see Fig 1B). The patch can be placed straddling the phrenic nerve, which is always identified and carefully avoided. A large patch is placed outside the pericardium adjacent to the right atrium anterior to the phrenic nerve and secured in a similar manner (Fig 1C). A transverse abdominal incision inferior to the left costal margin is made and a pocket developed in the subcutaneous space anterior to the rectus sheath (Fig 1D). Particular attention to hemostasis is necessary to minimize the risk of hematoma formation. All leads are tunneled subcutaneously to the left upper quadrant pocket using a chest tube as a guide. Standard intraoperative testing is performed to assure defibrillation thresholds of 20 J or less [3]. A 28F chest tube is placed in each pleural space. The ribs are reapproximated with two paracostal figure-of-8 polypropylene sutures, and all incisions are closed in layers with absorbable suture. Because of the incidence of perioperative supraventricular arrhythmias the device is not activated until the patient is transferred from the surgical intensive care unit to reduce the risk of unnecessary discharges. The chest tubes are removed routinely on the first postoperative day.
utomatic implantable cardioverter defibrillators have emerged as an effective tool in the management of patients with life-threatening ventricular arrhythmias refractory to drug therapy. Mirowski and associates [l] implanted the first automatic implantable cardioverter defibrillator in a human in 1980. The majority of patients requiring automatic implantable cardioverter defibrillator placement have ischemic cardiac disease and many have had a prior cardiac operation through a median sternotomy. Anterior-posterior placement of patch electrodes is difficult because of pericardial adhesions, and the risk of injury to adherent patent coronary bypass grafts is present. Extrapericardial patch lead placement has substantial advantages over epicardial placement. Intrapericardial dissection of previously operated regions is avoided and the risk of coronary artery bypass graft compression or erosion is minimized. In addition, ventricular compliance may be reduced with epicardial placement and subsequent scar formation. Extrapericardial patch leads have been as effective as epicardial placement with respect to energy requirements for successful termination of ventricular fibrillation in a canine model with experimentally induced pericardial adhesions and thickening [2]. From December 1986 to February 1992 we have used bilateral anterior thoracotomy, extrapericardial patches, and endocardial sensing lead placement in 40 patients at the University of Utah Medical Center with a prior history of sternotomy.
Technique A lumbar epidural catheter is placed before the induction of general anesthesia or at the completion of the proceAccepted for publication June 15, 1992 Address reprint requests to Dr Karwande, Division of Cardiothoracic Surgery, University of Utah Medical Center, 50 North Medical Dr, Salt Lake City, UT 84132.
0 1992 by The Society of
Thoracic Surgeons
0003-4975/92/$5.00
792
HOW TO DO IT KARWANDE AND ROWLES BILATERAL THORACOTOMY FOR AICD PLACEMENT
Ann Thorac Surg 1992;54:791-3
Fig 1 . Operative technique for bilateral anterior thoracotomy and placement of extrapericardial patch lead and endocardial sensing lead. ( A ) Incision for the right ventricular endocardial sensing lead through the left subclavian vein. ( B ) Left anterior thoracotomy and extrapericardial patch lead placement over the left ventricular apex. (C) Right anterior thoracotomy and extrapericardial patch lead placement adjacent to the right atrium. (D)Left upper quadrant incision and location of the automatic implantable cardioverter defibrillator generator.
Comment The most common technique for patch lead placement in patients with previous sternotomy has involved a left thoracotomy and anterior-posterior placement of patches. The anterior dissection is difficult because of scar, and the risk of injury to adherent coronary artery bypass grafts is present. In addition, defibrillation thresholds may be higher with anterior-posterior patch lead placement [4]. Extrapericardial patch lead placement reduces the risk of epicardial or coronary artery bypass graft erosion. Right ventricular perforation has been described with epicardial placement [5]. Ventricular compliance and diastolic filling may be adversely altered with epicardial patch leads and resultant scar formation. In addition, subsequent coronary artery bypass grafting is complicated by the dense fibrous tissue reaction beneath the epicardium and patches. Bilateral anterior thoracotomy allows optimal extrapericardial patch lead placement and may be performed quickly with two operating teams. The mean defibrillation
threshold was 15J, and the threshold was less than 20 J in all patients in this series. Postoperative pain is well controlled with epidural analgesia for 5 to 7 days. If the catheter becomes dislodged or malfunctions, it is replaced. Other invasive catheters are removed as early as possible to facilitate mobilization and improve respiratory mechanics. Incentive spirometry is used routinely; bronchodilator therapy and chest physiotherapy are used when indicated. This technique has been successfully used in patients with chronic obstructive pulmonary disease as well as those with amiodarone-induced pulmonary fibrosis. All patients have been extubated by the first postoperative day. Clinically significant pleural effusions have not occurred in any patient. This approach has simplified the placement of patch leads by avoiding dissection of previously operated regions without increasing pulmonary complications. Epidural analgesia for adequate pain control and early mobilization are important in the postoperative management of these patients.
Ann Thorac Surg 1992;54:791-3
References 1. Mirowski M, Reid PR, Mower MM, et al. Termination of malignant ventricular arrhythmias with an implanted automatic defibrillator in human beings. N Engl J Med 1980;3033224. 2. L~~~~~ JH, ~~b~~LA, ~~~i~~~ DJ, D~~~~ TA, fienzle MG, Behrendt DM. Pericardial influence on internal defibrillation energy requirements. J Thorac Cardiovasc Surg 1991;lOl: 83942. 3. Marchlinski FE, Flores 8,Miller JM, Gottliers DC, Hargrove
HOW TO DO IT KARWANDE AND ROWLES BILATERAL THORACOTOMY FOR AICD PLACEMENT
793
WC. Relation of the intraoperative defibrillation threshold to
successful postoperative defibrillation with an automatic implantable cardioverter defibrillator, Am Cardio1 1988;62: 393-8. 4. Lawrie GM, Kaushik RR, Pacific0 A. Right mini-thoracotomy: an adjunct to left subcostal automatic implantable cardioverter defibrillator implantation. Ann Thorac Surg 1989;47780-1. 5. Siclari F, Klein H, Troster J. Intraventricular migration of an ICD patch. PACE 1990;13:1356-9.
Notice From the American Board of Thoracic Surgery The American Board of Thoracic Surgery began its recertification process in 1984. Diplomates interested in participating in this examination should maintain a documented list of the operations they performed during the year prior to application for recertification. This practice review should consist of 1 year’s consecutive major operative experiences. (If more than 100 cases occur in 1 year, only 100 need to be listed.) They should also keep a record of their attendance at approved postgraduate medical education activities for the 2 years prior to application. A minimum of 100 hours of approved CME activity is required. In place of a cognitive examination, candidates for recertification will be required to complete both the general thoracic and cardiac portions of the SESATS IV syllabus (Self-Education/Self-Assessment in Thoracic Surgery). It is not necessary for candidates to purchase
SESATS IV booklets prior to applying for recertification. SESATS IV booklets will be forwarded to candidates after their applications have been accepted. Diplomates whose 10-year certificates will expire in 1995 may begin the recertification process in 1993. This new certificate will be dated 10 years from the time of expiration of the original certificate. Recertification is also open to any diplomate with an unlimited certificate and will in no way affect the validity of the original certificate. The deadline for submission of applications is May 1, 1993. A recertification brochure outlining the rules and requirements for recertification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201.
Bilateral anterior thoracotomy, extrapericardial patches, and endocardial sensing lead placement have been used in 40 patients with previous sternotomy. The mean defibrillation threshold was 15 J, and in all patients the defibrillation threshold was less than 20 J. The surgical procedure is simplified with less risk by avoiding dissection of previously operated regions. Serious pulmonary
complications have been avoided by adequate pain control with epidural analgesia and early mobilization. This technique has successfully been used in patients with underlying chronic obstructive pulmonary disease and amiodarone-induced pulmonary fibrosis. All patients have been extubated by the first postoperative day. (Ann Thorac Surg 1992;54:791-3)
A
dure for postoperative analgesia. Perioperative prophylactic antibiotics are used in all patients. The patient is placed supine on the operating table and the skin is prepared from the chin to the iliac crests. A single-lumen endotracheal tube is used for general anesthesia. A small incision inferior to the left midclavicle is made, and a right ventricular endocardial sensing lead is placed through the left subclavian vein using a modified Seldinger technique with fluoroscopic guidance (Fig 1A). Two operating teams perform simultaneous bilateral anterior thoracotomies through the fifth intercostal space for extrapericardial patch lead placement (Figs lB, 1C). Dissection of extrapericardial fat is not done unless it is necessary for direct pericardial placement of anchoring sutures. A large patch lead is placed on the left ventricle around the apex and secured with four interrupted nonabsorbable sutures at each corner (see Fig 1B). The patch can be placed straddling the phrenic nerve, which is always identified and carefully avoided. A large patch is placed outside the pericardium adjacent to the right atrium anterior to the phrenic nerve and secured in a similar manner (Fig 1C). A transverse abdominal incision inferior to the left costal margin is made and a pocket developed in the subcutaneous space anterior to the rectus sheath (Fig 1D). Particular attention to hemostasis is necessary to minimize the risk of hematoma formation. All leads are tunneled subcutaneously to the left upper quadrant pocket using a chest tube as a guide. Standard intraoperative testing is performed to assure defibrillation thresholds of 20 J or less [3]. A 28F chest tube is placed in each pleural space. The ribs are reapproximated with two paracostal figure-of-8 polypropylene sutures, and all incisions are closed in layers with absorbable suture. Because of the incidence of perioperative supraventricular arrhythmias the device is not activated until the patient is transferred from the surgical intensive care unit to reduce the risk of unnecessary discharges. The chest tubes are removed routinely on the first postoperative day.
utomatic implantable cardioverter defibrillators have emerged as an effective tool in the management of patients with life-threatening ventricular arrhythmias refractory to drug therapy. Mirowski and associates [l] implanted the first automatic implantable cardioverter defibrillator in a human in 1980. The majority of patients requiring automatic implantable cardioverter defibrillator placement have ischemic cardiac disease and many have had a prior cardiac operation through a median sternotomy. Anterior-posterior placement of patch electrodes is difficult because of pericardial adhesions, and the risk of injury to adherent patent coronary bypass grafts is present. Extrapericardial patch lead placement has substantial advantages over epicardial placement. Intrapericardial dissection of previously operated regions is avoided and the risk of coronary artery bypass graft compression or erosion is minimized. In addition, ventricular compliance may be reduced with epicardial placement and subsequent scar formation. Extrapericardial patch leads have been as effective as epicardial placement with respect to energy requirements for successful termination of ventricular fibrillation in a canine model with experimentally induced pericardial adhesions and thickening [2]. From December 1986 to February 1992 we have used bilateral anterior thoracotomy, extrapericardial patches, and endocardial sensing lead placement in 40 patients at the University of Utah Medical Center with a prior history of sternotomy.
Technique A lumbar epidural catheter is placed before the induction of general anesthesia or at the completion of the proceAccepted for publication June 15, 1992 Address reprint requests to Dr Karwande, Division of Cardiothoracic Surgery, University of Utah Medical Center, 50 North Medical Dr, Salt Lake City, UT 84132.
0 1992 by The Society of
Thoracic Surgeons
0003-4975/92/$5.00
792
HOW TO DO IT KARWANDE AND ROWLES BILATERAL THORACOTOMY FOR AICD PLACEMENT
Ann Thorac Surg 1992;54:791-3
Fig 1 . Operative technique for bilateral anterior thoracotomy and placement of extrapericardial patch lead and endocardial sensing lead. ( A ) Incision for the right ventricular endocardial sensing lead through the left subclavian vein. ( B ) Left anterior thoracotomy and extrapericardial patch lead placement over the left ventricular apex. (C) Right anterior thoracotomy and extrapericardial patch lead placement adjacent to the right atrium. (D)Left upper quadrant incision and location of the automatic implantable cardioverter defibrillator generator.
Comment The most common technique for patch lead placement in patients with previous sternotomy has involved a left thoracotomy and anterior-posterior placement of patches. The anterior dissection is difficult because of scar, and the risk of injury to adherent coronary artery bypass grafts is present. In addition, defibrillation thresholds may be higher with anterior-posterior patch lead placement [4]. Extrapericardial patch lead placement reduces the risk of epicardial or coronary artery bypass graft erosion. Right ventricular perforation has been described with epicardial placement [5]. Ventricular compliance and diastolic filling may be adversely altered with epicardial patch leads and resultant scar formation. In addition, subsequent coronary artery bypass grafting is complicated by the dense fibrous tissue reaction beneath the epicardium and patches. Bilateral anterior thoracotomy allows optimal extrapericardial patch lead placement and may be performed quickly with two operating teams. The mean defibrillation
threshold was 15J, and the threshold was less than 20 J in all patients in this series. Postoperative pain is well controlled with epidural analgesia for 5 to 7 days. If the catheter becomes dislodged or malfunctions, it is replaced. Other invasive catheters are removed as early as possible to facilitate mobilization and improve respiratory mechanics. Incentive spirometry is used routinely; bronchodilator therapy and chest physiotherapy are used when indicated. This technique has been successfully used in patients with chronic obstructive pulmonary disease as well as those with amiodarone-induced pulmonary fibrosis. All patients have been extubated by the first postoperative day. Clinically significant pleural effusions have not occurred in any patient. This approach has simplified the placement of patch leads by avoiding dissection of previously operated regions without increasing pulmonary complications. Epidural analgesia for adequate pain control and early mobilization are important in the postoperative management of these patients.
Ann Thorac Surg 1992;54:791-3
References 1. Mirowski M, Reid PR, Mower MM, et al. Termination of malignant ventricular arrhythmias with an implanted automatic defibrillator in human beings. N Engl J Med 1980;3033224. 2. L~~~~~ JH, ~~b~~LA, ~~~i~~~ DJ, D~~~~ TA, fienzle MG, Behrendt DM. Pericardial influence on internal defibrillation energy requirements. J Thorac Cardiovasc Surg 1991;lOl: 83942. 3. Marchlinski FE, Flores 8,Miller JM, Gottliers DC, Hargrove
HOW TO DO IT KARWANDE AND ROWLES BILATERAL THORACOTOMY FOR AICD PLACEMENT
793
WC. Relation of the intraoperative defibrillation threshold to
successful postoperative defibrillation with an automatic implantable cardioverter defibrillator, Am Cardio1 1988;62: 393-8. 4. Lawrie GM, Kaushik RR, Pacific0 A. Right mini-thoracotomy: an adjunct to left subcostal automatic implantable cardioverter defibrillator implantation. Ann Thorac Surg 1989;47780-1. 5. Siclari F, Klein H, Troster J. Intraventricular migration of an ICD patch. PACE 1990;13:1356-9.
Notice From the American Board of Thoracic Surgery The American Board of Thoracic Surgery began its recertification process in 1984. Diplomates interested in participating in this examination should maintain a documented list of the operations they performed during the year prior to application for recertification. This practice review should consist of 1 year’s consecutive major operative experiences. (If more than 100 cases occur in 1 year, only 100 need to be listed.) They should also keep a record of their attendance at approved postgraduate medical education activities for the 2 years prior to application. A minimum of 100 hours of approved CME activity is required. In place of a cognitive examination, candidates for recertification will be required to complete both the general thoracic and cardiac portions of the SESATS IV syllabus (Self-Education/Self-Assessment in Thoracic Surgery). It is not necessary for candidates to purchase
SESATS IV booklets prior to applying for recertification. SESATS IV booklets will be forwarded to candidates after their applications have been accepted. Diplomates whose 10-year certificates will expire in 1995 may begin the recertification process in 1993. This new certificate will be dated 10 years from the time of expiration of the original certificate. Recertification is also open to any diplomate with an unlimited certificate and will in no way affect the validity of the original certificate. The deadline for submission of applications is May 1, 1993. A recertification brochure outlining the rules and requirements for recertification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201.
