Videoscopic-guided retrosternal access for extravascular icd implantation: a technique to enhance safety and lead positioning

Background The extravascular implantable cardioverter-defibrillator (EV-ICD) offers a less invasive alternative to transvenous systems while maintaining effective defibrillation. Substernal tunneling remains the most challenging step, as limited visualization increases the risk of pleural or pericardial injury and suboptimal lead placement. Objective We aim to assess the safety and feasibility of a videoscopic-guided system (VSGS) to improve substernal access and lead positioning during EV-ICD implantation. Methods Patients underwent EV-ICD implantation using video-assisted substernal access with VSGS. Through a left lateral xiphoid incision, a thoracoscope was advanced to directly visualize the substernum and pericardium. Under combined video and fluoroscopic guidance, a tunneling tool was advanced from the xiphoid along the retrosternal space, ensuring continuous visualization to avoid pleural or pericardial breach. The lead was then passed into the retrosternal space anterior to the right ventricle and connected to the generator in the lateral pocket Procedural metrics, lead parameters, and acute complications were recorded. Results Nine patients (42% male, mean age 57 ± 12 years) successfully underwent EV-ICD implantation using the VSGS approach. Direct substernal visualization and first-pass lead placement anterior to the right ventricle were achieved in all cases. No pericardial or pleural entry, vascular injury, or need for surgical conversion occurred. Mean fluoroscopy time was 8 ± 6 minutes, and total procedure time was 26 ± 8 minutes. Defibrillation thresholds were acceptable with stable electrical parameters, and no acute complications or major device-related events were observed. Conclusion Real-time visualization with VSGS enables precise substernal RV lead placement and enhances safety during EV-ICD implantation. This early experience demonstrates feasibility and safety, though larger studies are needed to confirm broader applicability.