Subpectoral implantation of a cardioverter defibrillator under local anaesthesia

Abstract

Objective-To evaluate patient acceptability of submuscular implantation of a cardioverter defibrillator (ICD) under local anaesthesia with conscious sedation. Design-Retrospective review. Patient acceptability in the second half of the study was routinely assessed within 24 hours. Setting-Regional cardiac centre. Patients-45 consecutive patients with either aborted sudden death or haemodynamically unstable ventricular tachycardia were referred for ICD implantation. Interventions-A subpectoral implantation technique was employed. Twelve procedures were performed under general anaesthesia. Thirty three patients were sedated with midazolam and diamorphine, and local anaesthesia was achieved with bupivicaine. Ventricular fibrillation for defibrillation threshold testing was induced by alternating current, T wave shock, or ultrarapid burst pacing. Patients were contacted after the procedure to assess acceptability. Results-32 patients having implantation under local anaesthesia did not recall the surgical procedure. One patient described an awareness of "pushing" as the generator was positioned in the pocket. Seven patients said that the procedure was painless but recalled a test shock, four describing it as mildly uncomfortable. All 33 patients stated that they would be willing to have a second implant under local anaesthesia. Twelve patients who had the implant performed under general anaesthesia had no recollection of the procedure. Mean (SD) total procedure duration was significantly longer in those who had general anaesthesia (93 (16) v 67 (17) minutes; p = 0.0009). Conclusions-Subpectoral implantation of ICDs may be performed safely with patient acceptability under local anaesthesia with conscious sedation. (Heart 1998;79:253-255)

Permanent Pacemaker and Implantable Cardioverter-Defibrillator Implantation

“…The choice of anesthesia is related to operator preference or, in some cases, hospital protocol. [149][150][151] As previously mentioned, the procedure may be performed with either general anesthesia or intravenous sedation. In a patient in whom multiple defibrillation threshold determinations as well as subpectoral dissection are required, general anesthesia might be a better selection.…”

“…In addition to those approaches previously mentioned, the median sternotomy [146][147][148][149][150][151][152][153][154][155][156][157][158] has become the approach of choice for combination of open heart surgery and ICD implantation. 159,160 The common approaches for epicardial ICD implantation are the subxiphoid approach, subcostal approach, left lateral thoracotomy, and sternotomy.…”

Application of the Bispectral Index (BIS) During Deep Sedation for Patients with ICD Testing

“…Schematic procedure depends on the experience and standards of conduct 7 . For short-term cardiac procedures are recommended short-acting drugs, without the depressive effects on the cardiovascular system [11][12][13][14][15] . Clinical research comparing effects of etomidate, propofol and sodium thiopental, used for anesthetic during cardiac procedures didn't show any hemodynamic differences in these patients 8,9,10 .…”

“…Implantable cardioverter defibrillators are implanted under general anesthesia 12,13,14 or under local anesthesia 11,15 . Schematic procedure depends on the experience and standards of conduct 7 .…”

How should we cost ICD therapy?

“…Current UK practice, advocated by NICE [5], is for transvenous ICD implantation and device testing performed under local anaesthetic with conscious sedation in a cardiac catheter laboratory by cardiologists. This is far cheaper, and has been shown to be very acceptable to patients [14,15]. Indeed, this method was first reported in 1994 [16].…”