Substernal implant

Pre-procedural fluoroscopy – lateral and AP

•Subjects anatomy appropriate for substernal tunneling

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Marking the xiphoid process

•Rib margin

•Sternal midline

•Left lateral sternal border

•Top of cardiac silhouette

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Xiphoid incision

•Minimally invasive subxiphoid approach

•Small incision is made proximate & leftward the xiphoid process

•Blunt dissection is used to facilitate entry through the diaphragmatic attachments and into the anterior mediastinum

•Confirmation of substernal entry is performed by inserting a finger into the tunneling tract and feeling the underside of the sternum prior to introduction of the tunneling tool.

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Lead tunneled and secured

•Blunt tunneling rod backloaded with 9Fr sheath is then introduced into the substernal space

•Using alternating lateral and AP views sheath in tunneled ~ at or just left of the sternal midline

•Tunneling tool is removed, sheath remains, and lead is tunneled & secured

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Subcutaneous pocket

•Pocket made on left chest near the left midaxillary line

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DFT

•VF induction

•Assess appropriate sensing

•Shock output programmed 10J below max (max 40J, set at 30J)

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