Epicardial placement of implantable cardioverter-defibrillators in adults: Technical considerations, system performance, and clinical outcomes

BACKGROUND: Surgical implantation of epicardial implantable cardioverter-defibrillator (ICD) is considered when transvenous ICD placement is not feasible because of congenital anomalies, venous obstruction, or prior infections. Epicardial pacemakers are well-studied but less is known about contemporary epicardial ICD systems in adults. OBJECTIVES: This case series details the indications, techniques, safety, and long-term performance of surgically implanted epicardial high voltage (HV) coils and leads in adults. METHODS: We included all patients who received epicardial HV coils or leads at the Hospital of the University of Pennsylvania between 2014 and 2025. RESULTS: Nineteen patients (14 men, median age 64 years) were identified. Indications included ICD replacement after lead extraction for endocarditis (7), placement during concomitant surgery, including for tricuspid regurgitation (6), left ventricular assist device (3), and lack of venous access (3). HV coils were used in 58%, and 42% received epicardial leads. All patients received epicardial pace-sense leads; 68% received cardiac resynchronization therapy. HV coils or leads were sewn to the epicardium: 48% on the posterior left ventricle, 16% on the anterior right ventricle, 26% on both ventricles, and 11% in the transverse sinus. Two patients had impedances > 200 Ω because of a loose set screw and a damaged connector pin, respectively. Two had impedances < 20 Ω without clinical impact. One coil fractured 1.5 years post-implant. No failed shocks or lead migrations occurred. During a median follow-up of 468 days, 26% died, largely from advanced heart failure, none were attributable to surgery. CONCLUSION: Surgical implantation of epicardial ICD systems with HV coils/leads is safe and feasible. Multidisciplinary planning and long-term monitoring are essential.