Subpectoral Implantation of Cardiovascular Implantable Electronic Device: A Reasonable Alternative for the Conventional Prepectoral Approach

Fig. 1. (A) The axillary incision is seen behind the anterior axillary line. The extent of the subpectoral pocket is drawn in broken lines, and the predicted location of the device is also drawn in the vicinity of the nipple. (B) After skin incision and dissection to the lateral border of the pectoralis major muscle. (C) The pectoralis major muscle has been pulled upward and the subpectoral space is easily visualized. (D) The cardiologist uses this approach to insert leads, which are seen extending out of the skin incision. The surgeon estimates the location of the device and checks if the leads will reach the device without tension. (E) After the device is connected to the leads and inserted in the planned subpectoral plane, the skin is closed using absorbable sutures

Fig. 2. (A) 72 year-old male who underwent subpectoral ICD insertion two months ago. (B, C) The short axillary incision scar is visible only when the patient’s arms are held up, and even then only barely

Fig. 3. A 35 year-old female patient who underwent a subpectoral implantation 11 months ago with an additional subclavian venous approach. (A) The subclavian scar is visible upon anterior view. There is no asymmetry of the breasts. (B, C) The axillary incision is barely discernible even when the patient lifts her arms up

Fig. 4. A 23 year-old female patient who underwent subpectoral implantation four months ago via the axillary approach. (A, B, C) The patient’s breasts are symmetric and the axillary scar is barely visible

Fig. 5. A 79 year-old female patient who underwent conventional prepectoral implantation. (A) The skin overlying the device had become very thin and showed infection signs. (B, C, D) After pocket change to the subpectoral pocket and excision of necrotic skin. the patient no longer could palpate the device, and risk of device protrusion was minimized