Does an ICD in Left Infraclavicular Pocket Hinder Access During Myocardial Bridge Unroofing Surgery?
A left infraclavicular implantable cardioverter-defibrillator (ICD) does not typically hinder surgical access for myocardial bridge unroofing procedures, as these are performed through different surgical approaches targeting the anterior heart surface.
Surgical Approaches for Myocardial Bridge Unroofing
Myocardial bridge unroofing procedures can be performed through several approaches, none of which are typically impeded by a left infraclavicular ICD:
Sternotomy approaches:
- On-pump sternotomy
- Off-pump sternotomy
Minimally invasive approaches:
- Off-pump minithoracotomy
- Robotic totally endoscopic approach
The surgical access for myocardial bridge unroofing targets the left anterior descending (LAD) coronary artery, which is approached through the anterior chest wall via sternotomy or through smaller, targeted incisions in minimally invasive approaches 1, 2.
Anatomical Considerations
- The left infraclavicular ICD pocket is located in the subcutaneous tissue beneath the clavicle
- Myocardial bridge unroofing targets the LAD coronary artery on the anterior surface of the heart
- These are anatomically distinct areas with different surgical approaches
Surgical Techniques for Myocardial Bridge Unroofing
Recent advances in myocardial bridge unroofing techniques have expanded surgical options:
- Off-pump minithoracotomy has shown excellent results with shorter hospital stays (median 3.0 days) compared to sternotomy approaches (4.0-5.0 days) 2
- Robotic totally endoscopic off-pump unroofing has been successfully performed in selected cases 3
These minimally invasive approaches further reduce any potential interference from an ICD device, as they use targeted access points that avoid the infraclavicular region.
ICD Considerations During Surgery
While the ICD itself doesn't hinder surgical access, there are important perioperative considerations:
- The ICD should be interrogated before surgery
- Deactivation of tachyarrhythmia detection/therapy during surgery to prevent inappropriate shocks from electromagnetic interference
- Reactivation and interrogation after surgery
- Careful electrocautery management to prevent device damage
Potential Rare Complications
In rare cases where surgical revision of the ICD pocket might be needed simultaneously with myocardial bridge unroofing:
- Infection risk would increase with concurrent procedures
- The HRS/ACC/AHA guidelines recommend avoiding concurrent procedures when possible to reduce infection risk 4
Conclusion
Myocardial bridge unroofing can be safely performed in patients with a left infraclavicular ICD using various surgical approaches. The anatomical separation between the ICD pocket and the surgical field for myocardial bridge unroofing means there is minimal interference between the two. Modern minimally invasive techniques further reduce any potential conflicts between the device and surgical access.