Cardioverter-Defibrillator Implantation Periprocedural Care

Updated: Apr 01, 2014
  • Author: Adam S Budzikowski, MD, PhD, FHRS; Chief Editor: Richard A Lange, MD, MBA  more...
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Periprocedural Care

Equipment

Equipment used in the placement of an implantable cardioverter-defibrillator (ICD) includes the following:

  • Fluoroscope
  • Surgical tray
  • Peelable hemostatic sheath(s)
  • External defibrillator
  • ICD generator and lead(s)
  • Pacing cable(s)
  • Analyzer

ICD systems consist of a pulse generator and pacing leads. Endocardial leads are inserted transvenously and advanced to the right ventricle, where they are implanted into the myocardial tissue. The pulse generator is placed subcutaneously or submuscularly in the chest wall.

On September 28, 2012, the U.S. Food and Drug Administration approved the first subcutaneous implantable cardioverter defibrillator for ventricular tachyarrhythmias which allows the lead to be placed under the skin rather than through a vein into the heart. [8]

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Patient Preparation

Anesthesia

For the overwhelming majority of patients, local anesthesia with lidocaine and conscious sedation are sufficient. Local anesthetic should be infiltrated into the skin and subcutaneous tissue. The entire area can be effectively anesthetized with 1 or 2 injections with repositioning of the needle. Repeated penetration skin by the anesthetic needle should be avoided, because it increases the risk that bacteria will be introduced.

In selected patient populations, consideration should be given to general anesthesia; such populations include pediatric patients, as well as patients in whom subpectoral device placement will be performed and those who will require lead tunneling.

Positioning

The chest should be shaved with a clipper rather than with a razor to avoid skin injury, which creates a portal for bacteria entry. The patient’s hair should be secured with a surgical hat because of its proximity to the incision.

The patient should be positioned supine. In rare cases, left arm extension may be necessary to allow submammary device placement. External defibrillation patches should be placed anteriorly and posteriorly.

The author prefers that the ICD insertion area be first cleaned with detergent solution, then dried and subsequently prepared with chlorhexidine-based products; this may promote more rapid healing after ICD insertion and may diminish bacterial growth. Patients should also undergo a whole-body wash (including a hair wash) with a disinfecting solution 24 hours before implantation.

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