Percutaneous Epicardial Defibrillation Coil Implantation

Received December 8, 2009; revision accepted February 9, 2010. A 70-year-old African American female with known history of nonischemic cardiomyopathy (ejection fraction, 15%) was referred for BiVentricular implantable cardioverter-defibrillator (BiV-ICD) implantation for primary prevention. Because of a previous left mastectomy for breast cancer and occlusion of the left subclavian axillary venous system, a right-sided prepectoral implant was chosen for this patient. The procedure included a right-sided prepectoral BiV-ICD implantation, implantation of a right atrial appendage active fixation lead, a single-coil active fixation right ventricular lead, and a left ventricular coronary sinus lead. During the routine testing of the ICD, the defibrillation threshold (DFT) was >35 J, requiring external cardioversion. A second DFT testing performed thereafter with a polarity modification was also >35 J. The patient was subsequently treated with sotalol 80 mg bid for 1 week and the DFT was repeated but was still refractory (>35 J). Hence, alternate options were entertained. Although a left-sided subcutaneous coil array was considered, it was abandoned because the coil extension had to cross the midline of the chest. However, a percutaneous epicardial defibrillation coil implantation was considered (Figure 1A). Figure 1. A, Anteroposterior chest radiograph showing the BiV-ICD generator in the right prepectoral region with the defibrillation coil (halo) in the pericardial space. B, Subxyphoid approach (arrow) to access the pericardial space. Note …