Percutaneous Endoscopic Implantation of Automatic Implantable Cardioverter/Defibrillator (AICD): An Animal Study of a New Nonthoracotomy Technique

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Abstract
The Automatic Implantable Cardioverter/Defibrillator (AICD) prevents death due to malignant ventricular arrhythmias but requires thoracotomy for the implantation of the preferred two-patch lead system. The purpose of this study was to develop and test a new percutaneous endoscopic method of the AICD lead implantation without the need for open chest surgery. A high resolution video endoscopy system and currently available endoscopic instrumentation were used to develop pleural-pericardial dissection technique in 7 pigs and to endoscopically implant custom-made AICD patches in 20 pigs. An examining 10 mm rigid endoscope inserted in the 6th intercostal space in the anterior axillary line provided direct visual control for endoscopic dissection of the parietal pleura from the pericardium, delivery, and implantation of the AICD patches. This was successfully carried out through two trocars (10 and 11 mm) inserted into the pleural-pericardial space via the subxyphoid approach in 18 of 20 pigs. Effective patch positioning was confirmed by attaining a defibrillation threshold of 20J or less in 13 pigs. Of those, three required lead polarity reversal, and three others required lead repositioning to lower defibrillation thresholds to 20J or less. In three pigs, defibrillation thresholds of 30J or higher were required. Defibrillation was unsuccessful in two pigs due to patch malfunction. The authors conclude that percutaneous endoscopy is a feasible method of AICD lead implantation.