Giant lambl excrescences. An unusual source of cerebral embolism.

BACKGROUND: A possible association of giant Lambl excrescences (LEs) with stroke has been suggested. However, the treatment of giant LEs is controversial because minimal data are available. OBJECTIVE: To clarify the management of giant LEs through a clinicopathologic study. CASE SERIES: Three young patients (2 women and 1 man) who experienced ischemic stroke were studied. Results of general examinations were normal, as were chest x-ray films, electrocardiograms, ultrasonograms of the neck, and cerebral angiograms. Extensive serological and blood testing failed to show any coagulopathies or systemic disorders that favored a stroke in these patients. Transesophageal echocardiography showed a mitral valve lesion (width, > 1 mm). Two patients (cases 1 and 3) were discharged on a regimen of anticoagulant therapy and sequential transesophageal echocardiographic monitoring was planned, whereas 1 patient (case 2) was promptly scheduled for surgery. A second stroke occurred in patients 1 and 3 at 3 and 6 months, respectively, thus leading to surgery in these 2 patients. Findings from histopathologic studies were consistent with the diagnosis of giant LEs. The patients' outcomes were uneventful after surgery, and none had a recurrence of a stroke. CONCLUSIONS: A relationship between giant LEs and stroke may be suggested. In patients who have transesophageal echocardiographic findings that are consistent with this diagnosis and recurrent stroke despite antithrombotic therapy and without an alternative explanation for the ischemic symptoms, surgery should be considered in view of these findings.

Outcome of atrial fibrillation after mitral valve repair.

OBJECTIVE: The aim of the study was to evaluate the prognostic factors for return to sinus rhythm after mitral valve repair. METHOD: One hundred ninety-one patients underwent surgery for mitral valve repair, including 142 procedures for valve repair only (74%). The patients with preoperative atrial fibrillation (50.5%) were older, clinically more symptomatic, and had a greater degree of left atrial dilation than the patients who had sinus rhythm. RESULTS: Preoperative cardiac rhythm, the duration of preoperative atrial fibrillation, and a lesser degree of left atrial hypertrophy are significant prognostic factors independent of the maintenance of sinus rhythm. The probability of return to stable sinus rhythm was 93.7% when sinus rhythm was already present before the operation and 80% when atrial fibrillation was intermittent or of less than 1 year's duration; probability declined abruptly for durations over 1 year. No significant difference in patient survival was noted between those who had sinus rhythm (99% +/- 0.9% at 1 year and 86% +/- 6.6% at 5 years) and those who had atrial fibrillation in the preoperative period (95% +/- 3.1% at 1 year and 86% +/- 8.4% at 5 years). In contrast, the postoperative return to sinus rhythm was associated with 99% +/- 0.9% and 94% +/- 4.8% survivals at 1 and 4 years versus 97% +/- 1.5% and 77% +/- 13% in the event of postoperative atrial fibrillation. CONCLUSION: The aim of restoring postoperative sinus rhythm after mitral valve repair should lead to surgery being conducted on patients who have sinus rhythm or recent-onset atrial fibrillation. Surgery for atrial fibrillation may be of value in patients with a long history of atrial fibrillation, providing that it does not induce prohibitive excess mortality.

Long conservation organs in heart transplantation: postoperative results and long-term follow-up in fourteen patients.

Between 1988 and 1995, 14 heart transplantations were performed after a long preservation period (10 to 13 hours). The transplantation procedure (Shumway) was standard, and our results were achieved through the implementation of a very strict reperfusion technique that included low pressure and low cardiopulmonary bypass output for the first 10 minutes. Three patients died during the postoperative period, and the survival rate was 75% at 1 year and 71% at 5 years. The results obtained with hearts stored for such long periods are comparable to the results obtained with hearts stored for less than 4 hours.

Subdiaphragmatic implantation of implantable cardioverter defibrillator generator.

Despite several improvements in the surgical technique and in the technologic design of cardioverter defibrillators made over the past years, abdominal placement of the generator device, done as Mirowski did it in his first implantation performed in 1980, remains the widely used method. Although smaller defibrillators are available, they remain bulky and are a source of local complications. To prevent such complications and to enhance patient comfort, we performed a subdiaphragmatic implantation in 31 patients.

Long-term follow-up of small (size 20 and 21) Medtronic-Hall aortic valve prostheses.

BACKGROUND: Our goal was to study the long-term follow-up of patients having aortic valve replacement and to focus particularly on the patients receiving small prostheses. METHODS: Four hundred twenty-eight Medtronic-Hall valves were implanted (156 size 20 or 21 mm, 149 size 22 or 23 mm, and 123 size 25 or 27 mm). Group 20-21 had a higher number of female patients, more associated coronary lesions, and more patients with aortic stenosis. RESULTS: The actuarial survival rate at 8 years was 80% for group 20-21, 80% for group 22-23, and 76% for group 25-27 (p = not significant). In group 20-21, the actuarial event-free rates at 8 years were as follows: thromboembolic complications, 94%; prosthetic valve endocarditis, 99%; reoperation, 98%; and hemorrhagic complications, 78%. The only factors of prognostic value in this group were age and associated coronary lesions. CONCLUSIONS: The durable nature of the results obtained with the Medtronic-Hall 20- and 21-mm prostheses compared with large-diameter prostheses allows the use of a simple and reliable surgical technique and should mean that indications for ring enlargement become rare.

Effect of cardiopulmonary bypass on plasma concentrations of diltiazem and its two active metabolites.

Diltiazem is often used to prevent myocardial ischaemia during the perioperative period of coronary artery bypass surgery. The purpose of this study was to investigate the effect of cardiopulmonary bypass (CPB) on plasma concentrations of diltiazem and of its two main and active metabolites (N-monodemethyldiltiazem (N-desmethyldiltiazem) and desacetyldiltiazem). The patients were administered their usual treatment during the preoperative days. The last dose was administered immediately before anaesthesia. At the onset of CPB, a significant decrease in the plasma concentrations of diltiazem and its metabolites was observed, whereas the variation was slight and not significant when the plasma concentrations were corrected for haemodilution. These results confirm that the decrease observed at the initiation of the bypass procedure can be ascribed to the haemodilution induced by the CPB. During CPB, the concentrations of diltiazem and its metabolites remained constant suggesting that the rate of metabolism and excretion of the drug was altered during the bypass procedure. At the end of CPB, there was no increase of drug plasma concentrations suggesting that no redistribution of diltiazem from tissues to plasma occurred. Furthermore, this study shows that only 33% of subjects have therapeutic levels of diltiazem before anaesthesia, and that all subjects have subtherapeutic levels during and after the CPB. These results suggest that a higher chronic oral dose of the drug should be given in patients undergoing cardiac surgery with CPB.

Valvular replacement for aortic stenosis on patients in NYHA class III and IV. Early and long term results.

From January 1972 to June 1990, 112 patients between 39 and 83 years old, divided into 68 NYHA class III (60.72%) and 44 NYHA class IV, underwent surgery for aortic stenosis. There were 67 male (59.82%) and 45 female (40.18%). Early mortality included 8 patients (7.14%). Actuarial survival (including early postoperative mortality) for all 112 patients was 88.39%, 77.67%, 67.85% and 65.7% t one year, five, ten and fifteen years respectively. Clinical criteria are subjective but they remain the best prognostic factor. Surgery is indicated at occurrence of first symptoms, but, even in advanced cases, aortic valvular replacement can significantly improve survival and functional status. Even if operative risk is increased and secondary cardiomyopathy often progresses after surgery, aortic valve replacement results seem better than those of medical treatment alone.

Defibrillation threshold and electrode configurations: an experimental study testing three configurations in twelve pigs.

OBJECTIVE: The choice between epicardial or subcutaneous patches remains unclear and depends essentially on the team's habits. This study tested how much an additional patch can decrease defibrillation threshold (DFT), and compared a Subcutaneous Array and an epicardial patch. Today most implantable automatic defibrillators have a transvenous endocardial configuration alone but when the DFT remains high an additional patch is necessary. EXPERIMENTAL DESIGN: Three different configurations were tested with biphasic shocks in 12 pigs: Endovenous lead (Endo), Endovenous lead + subcutaneous patch (Endo + SQ) and Endovenous lead + epicardial patch (Endo + Epi). For each animal DFTs were determined in a balanced random order for the 3 configurations. Ventricular fibrillation was induced by pacing (30 Hz, 8 V, for 5 seconds). DFT was accurately measured with the up/down procedure until 3 reversal of defibrillation success or failure occurred. DFTs (mean +/- SD) were extracted and compared using paired t test and analysis of variance. RESULTS: DFTs were 14.6 +/- 11.0 J for Endo and significantly decreased (p < 0.01) when an additional SQ (9.4 +/- 7.2 J) or epicardial patch (8.9 +/- 6.5 J) was added to endovenous lead, without significant difference between Endo + SC and Endo + Epi configurations. CONCLUSIONS: Regarding this important decrease of DFT (respectively -35% for Endo + SC and -39% for Endo + Epi), additional patches should be more often recommended in patients with low safety margin of DFT. In those cases subcutaneous patches should be preferred instead of epicardial patches. Moreover, an additional reason to recommend this attitude could be the possible generator batteries saving.

[Thoracic aortic aneurysm in Marfan syndrome]. / Anévrysme de l'aorte thoracique dans la maladie de Marfan.

Thoracic aortic aneurysms are the main cardiovascular complication of Marfan's syndrome. Elastic tissue dystrophy of the ascending aorta is responsible for appearances of cystic medial necrosis in the major forms. Dilatation of the ascending aorta is progressive with time. The risk of dissection and rupture, an acute complication of Marfan's syndrome, is very high when the aortic dilatation reaches 60 mm, although dissection may be observed with dilatation of 50 mm. Aortic regurgitation is found in half the cases. Echocardiography, CT scan and MRI provide accurate assessment of the anatomy of the lesions and help in following up the dilatation. Betablocker therapy slows down the progression of the dilatation. Bentall's procedure was first described in 1968 with its technical variants for reimplantation of the coronary arteries: Cabrol's procedure, technique of periostal lean-to, the button technique, are major advances in the surgical treatment of ascending aortic aneurysms. The life expectancy is reported to be about 90% at 5 years and 75 to 80% at 10 years. Reoperation is sometimes necessary because of pseudo-aneurysms occurring as a late complication at the operation site or because of other aneurysms developing. Progress in the field of genetics is a hope for the future.

[Angiography in bypass grafts of the left anterior descending coronary artery with the left internal mammary artery. Apropos of 100 control examinations with a maximum follow-up of 6 years and 8 months]. / Etude angiographique des pontages de l'artère inter-ventriculaire antérieure par l'artère mammaire interne gauche. A propos de 100 examens de contrôle avec un recul maximum de 6 ans et 8 mois.

Ninety three patients underwent 100 angiographic control studies of a left internal mammary artery bypass of the left anterior descending artery. The controls were carried out between 11 days and 6 years 8 months after surgery. Seven patients underwent two control studies. The patients were divided into three groups:--60 early control angiographic studies (before 2 years);--16 late control angiographic studies (between 2 and 5 years);--24 very late systematic control angiographic studies (after 5 years). The patency rate of the arterial grafts was 99%. From the anatomical point of view, the arterial walls of the internal mammary artery appeared smooth and regular except in one case. There was no cases of bypass graft disease. The ratio of the diameters of the internal mammary and left anterior descending arteries was greater than or equal to 1 in 93% of cases. The adaptation of the diameter of the internal mammary artery to that of the left anterior descending artery is an early phenomenon as shown by statistical and repeat control studies. The number of remaining collateral vessels does not appear to have an effect on the diameter of the internal mammary artery. Stenosis at the site of anastomosis was observed in 16% of cases. This seemed to be favoured when the angle subtended by the two vessels reached 90 degrees. The haemodynamic changes of the coronary circulation (competition of flow, competition of flow in the distal vessels, reflux in the internal mammary graft) were comparable to those observed in aorto-coronary saphenous vein bypass.

[Aortic insufficiency caused by dystrophic aneurysm of the ascending aorta: study of development in 95 cases. Value of cutaneous biopsy in the etiologic diagnosis]. / Les insuffisances aortiques par anévrysme dystrophique de l'aorte ascendante: étude évolutive de 95 observations. Intérêt de la biopsie cutanée dans le diagnostic étiologique.

We present 95 cases of aortic valve incompetence (AI) due to a dystrophic aneurysm of the ascending aorta; the aneurysm was idiopathic in 83 cases and associated with Marfan's syndrome in 12 cases. The diagnosis was confirmed by histological examination of the aorta and aortography. Functional signs were not always present, since 42 p. 100 of patients were in NYHA classes I and II and 58 p. 100 in classes III and IV. The prevalence of angina was 26 p. 100. The cardiothoracic ratio was increased up to 0.62 +/- 0.07, and projection to the right was noted in 63 p. 100 of the cases. Sokolow's index was 5 mv or more in 24 p. 100 of the patients. The aortic root, measured in 42 patients, was dilated up to 54 +/- 13 mm. The end-diastolic left ventricular diameter was increased to 70 +/- 10 mm. Haemodynamic studies yielded the following results: cardiac index 2.33 +/- 0.6 1/min/m2, end-diastolic left ventricular pressure 24.7 +/- 12 mmHg, mean pulmonary wedge pressure 12 +/- 6 mmHg, left ventricular end-diastolic volume 199 +/- 67 ml/m2, and angiographic ejection fraction 53 +/- 12 p. 100. The angiographic volume of aortic regurgitation, graded according to Sellers' classification, was 3/4 or 4/4 in 89 patients; the maximum diameter of the dilated ascending aorta was 73 +/- 18 mm. Evolutive data confirmed that aortic incompetence due to dystrophy is more severe than that due to other causes: 36 months after surgery, the overall mortality rate was 30%. Only two factors in our series seemed to be predictive of a poor prognosis: the fact that the patient belonged to NYHA class III or IV, and a mean pulmonary wedge pressure above 10 mmHg. This, however, must be taken with caution in view of the small population samples studied. The value of skin biopsy was confirmed. This examination, performed in 27 patients, was compared with the pathological examination of the aorta. Skin biopsy is specific and provides a major argument in favour of dystrophic AI in patients under 40 years of age.

[Evaluation of the results of myocardial revascularization surgery by exercise tests under electrocardiographic control. Correlations with control coronography].

A myocardial revascularisation procedure was carried out on 68 patients with obstructive atheroma of the coronary arteries associated with severe angina pectoris. In 58 cases a total of 97 vein grafts were used, and in 10 cases the internal mammary artery was anastomosed to the anterior descending artery (using a vein graft in 5 of them). Before operation the patients had selective coronary arteriography, and a maximal exercise test using a bicycle ergometer. Three months postoperatively the patency of the coronary by-pass was checked, and a further exercise test completed. In the exercise test the criteria were the appearance of angina pectoris, improved performance (measured by the duration of exercise, the maximal power, and the heart rate at the end of exercise), and improved ECG findings. These criteria were correlated by the patency of the graft or grafts as noted at arteriography. There was no pain on exercise in 55 patients (81 per cent), the performance improved in 37 (54 per cent), and the ECG findings improved in 50 (72 per cent). At angiography, 34 patients (50 per cent) had a completely patent by-pass (group I), 31 patients (45.5 per cent) had at least one patent graft (group II), and 3 patients (4.4 per cent) had no patent graft (group III). Group I corresponds to 31 good or very good results and to 3 states on non improvement; group II contains 22 good results and 9 states of non improvement; group III corresponds to 3 states of non improvement. Exercise demonstrates the results of myocardial revascularisation surgery; the correlations between these results and those of graft patency justify its use in surveillance of coronary patients who have been operated. Exercise tests show that the best results are obtained in patients with severe functional disturbances and whose ventricular cinetics have remained sufficient.

[Coronary bypass surgery. Results after 5 years : mortality - morbidity]. / La chirurgie de pontage coronarien. Résultats après 5 ans : mortalité - morbidité.

The improvement in the expectation and quality of life of patients undergoing coronary bypass surgery has been studied in the short term but there are relatively few studies with follow-up periods of over five years. The results in 239 patients operated on between 1970 and 1976 are presented. The preoperative data was obtained from a computerised filing system; studies were made at 3 months, at an average of 60 months, and in 78 patients with follow-up exceeding 5 years. Actuarial survival rates were calculated. The operative mortality was 9 patients (3,7%); late mortality was 21 patients (9,2%). Most deaths were due to cardiac causes. The following factors did not appear to be associated with a poor prognosis: sex, the number of cardiovascular risk factors, the number of bypass grafts; however, age and poor left ventricular function as identified by ECG (p less than 0,01), the presence of clinical cardiac failure (p less than 0,001) and by angiography (p less than 0,001) were associated with a poor prognosis. The long-term functional results were interesting: 67% patients followed up to 5 years and 56% patients followed up for over 5 years had no angina. Myocardial infarction occurred in 16,7% of patients at 5 years. Preexisting left ventricular failure which affected the operative and immediate postoperative results was also found secondarily in 9% of patients at 5 years. In the long term, the annual mortality rate seemed to be less in patients with triple vessel disease after myocardial revascularisation. The annual mortality rate of patients with left anterior descending disease alone did not seem to be improved when compared with medically treated patients until after the third year. Once again, the extent of myocardial disease was shown to be the essential prognostic factor whatever the coronary profile of the patient. In this study patients with severe angina or unstable angina who had been treated medically before surgery had the same results as those treated surgically by first intention; this fact is an argument in favour of initial medical management in all forms of angina.

[Automatic implantable defibrillators; subdiaphragmatic insertion]. / Défibrillateur automatique implantable; mise en place sous-diaphragmatique du boîtier.

Although the material and techniques of implantation of the electrodes of implantable defibrillators have been improved, the abdominal implantation of the generator remains widely used as described by Mirowski in 1980. Despite a progressive reduction in their size, the generators remain bulky and a source of local complications. The risks and discomfort of implantation in the abdominal wall led the authors to try subdiaphragmatic implantation in 22 patients. There was no morbidity with perfect healing in all 22 cases. The mean follow-up period was 11 months. The patients felt very comfortable, a significant advance with respect to abdominal implantations.

[Aneurysms of the left ventricle without atheromatous coronary artery disease. Apropos of 2 cases]. / Les anévrysmes du ventricule gauche sans lésions coronaires athéromateuses. A propos de deux observations.

Left ventricular aneurysms are usually secondary to myocardial infarction with atheromatous coronary artery disease. The authors report two rare cases of non-atheromatous left ventricular apical aneurysms. The first case was clearly post-traumatic but the diagnosis in the second case was more difficult. The authors discuss the aetiological diagnosis of these rare non-atheromatous aneurysms in adults and the therapeutic management with respect to these two cases and a review of the literature.

[Discussion on therapeutic attitude in Prinzmetal's angina. Apropos of 6 cases]. / Discussion de l'attitude thérapeutique dans langine de Prinzmetal. A propos de 46 observations

1. 46 cases of Prinzmetal's angina have been studied: there were 36 males and 10 females, with an average age of 54.6 years. 19 patients (group A) were treated medically, and 12 of these were followed up for more than 6 months (average follow-up period 45.1 months). 27 patients (group B) underwent a coronary by-pass procedure: 22 of these were followed up for more than 6 months after surgery (average postoperative follow-up period 21.6 months). 2. One patient from group A and two patients from group B died, one of them from postoperative renal failure. None of the three deaths could be attributed directly to the coronary artery disease. 2 patients from group A and 5 patients from group B had a myocardial infarction without fatal outcome. 5 of the 12 patients in group A and 16 of the 22 patients in group B were asymptomatic after more than 6 months of follow-up. 3. The treatment policy should take account: - of the prognosis of Prinzmetal's angina, which is on the whole better than that of an unstable angina pectoris of the common type; - of an assessment of the risks in each individual case; these are increased when there is a combination of risk factors for atherosclerosis, and/or severe arrhythmia with syncope, and/or persistant electrical changes in the territory of the anterior descending artery, and/or coronary artery lesions involving two or three major vessels. 4. Surgery is used if there is a failure of treatment with beta-blockers, which are used under cover of a pacemaker when there is a paroxysmal block. If medical treatment is successful, surgery is indicated in high-risk cases.

[Course of the results observed in the 1st 100 coronary angioplasties performed in 96 patients. Experience in Lyons]. / Evolution des résultats observés pour les 100 premières angioplasties coronaires réalisées chez 96 patients. Expérience lyonnaise.

TCA is an original method of myocardial revascularisation which, when successful, enables coronary bypass surgery to be avoided. However, a certain number of failures and complications are inherent to the development of a new therapeutic technique. The object of this study is to analyse the evolution of our results with this technique to determine which factors changed as our experience increased. The methodology used was that initially described by A. Gruntzig. TCA was carried out 72 times on the left anterior descending, 20 times on the right coronary and 8 on the left circumflex coronary artery (72 single vessel, 28 multivessel disease). The primary success rate was 75% (72% for the first 50 and 78% for the second 50 procedures). Coronary bypass surgery was required within the first 24 hours of TCA in 7% of cases. Myocardial infarction (Q wave changes) was observed in 5% of cases. One patient died on the third day (occlusion of an aorto-coronary venous graft). In retrospect, taking into account the experience gained and the development of the material now available, a certain number of failures and complications could probably have been avoided. However, a certain number of complications seems to be unavoidable. TCA remains an inviting but not infallible alternative in the treatment of coronary artery disease and should be included in the medico-surgical management of this condition.

[Tricuspid valve replacement by Hancock's prosthesis]. / Le remplacement valvulaire tricuspidien par la prothèse de Hancock.

The medium term results of tricuspid valve replacement with the Hancock bioprosthesis are reported. Twenty eight patients underwent tricuspid valve replacement with this prosthesis between December 1974 and January 1978: mitral valve replacement with a Starr-Edwards or Cooley-Cutter prosthesis was associated in all cases and aortic valve replacement with a Björk-Shiley prosthesis in 11 cases. Follow-up at an average of 36,2 months after operation examined functional status, cardiac size and haemodynamics (in 12 patients). Three patients died in the immediate postoperative period and four others died later: the number of survivors was greater in the triple valve replacement (9/11) than in the double valve replacement group (12/17) but the difference was not statistically significant. Of the 23 surviving patients (average follow-up of 36,2 +/- 9,6 months), 17 were classified in functional Classes I or II of the NYHA classification. All patients had been Class III or IV before operation. The cardiothoracic ratio did not decrease significantly in patients undergoing triple valve replacement. Control cardiac catheterisation showed a significant increase in cardiac index (2,53 +/- 0,11 1/mn/m2, compared to 1,87 +/- 0,35 1/mn/m2 before operation; p less than 0,001) without significant reduction in pulmonary artery or right atrial pressures. The resting gradient across the Hancock bioprosthesis was not related to the size of the prosthesis (No 29-30: 2,17 +/- 2,57 mm Hg; No 31-33: 2,78 +/- 3,53 mm Hg) or with the quality of the functional result. However, on exercise, the gradient across the prosthesis was high, reaching an average of 10,3 +/- 5,2 mm Hg). The operative mortality of tricuspid valve replacement is relatively bioprosthesis associated with mitral and/or aortic valve replacement is relatively bioprosthesis associated with mitral and/or aortic valve replacement is relatively low (about 10%) and could be an argument in favour of broadening the indications for tricuspid valve replacement as resting tricuspid function with a bioprosthesis is satisfactory. However, the stenotic effects on exercise and the uncertainty over the long-term outcome of bioprostheses suggest that surgery should be limited to severe tricuspid stenoses and/or major tricuspid regurgitation organic or functional uncontrolled by digitalis and diuretic therapy.

[Reversible graft dysfunction after cardiac transplantation]. / Dysfonction réversible du greffon après transplantation cardiaque.

The authors report 3 cases of major graft dysfunction after cardiac transplantation which recovered completely with biventricular mechanical assistance in 4 to 8 days. All three cases were primary biventricular graft failures in patients with normal preoperative pulmonary resistances. These early dysfunctions (with no signs of myocardial infarction on electro- or echocardiography and in the absence of abnormal increased peri-operative enzyme levels) associated with total functional recovery conforming to the definition of the phenomenon of myocardial stunning. These results argue in favour of aggressive management of primary graft dysfunction.

[Implantation of automatic defibrillators by means of video-thoracoscopy. Authors' experience]. / L'impianto dei defibrillatori automatici mediante video-toracoscopia. La nostra esperienza.

The implantable cardioverter-defibrillator represents an effective option for some potentially lethal ventricular arrhythmias. Nowadays defibrillation electrodes are often endoluminal only. In some patients, however, the presence of high defibrillation thresholds mandates the implantation of a subcutaneous patch. If the subcutaneous patch does not allow a sufficient decrease in defibrillation threshold, then two epicardial patches are generally implanted by different surgical approaches. Nevertheless surgical trauma could be a serious hazard in unstable patients. In 6 patients in whom endoluminal electrodes did not allow a safe defibrillation threshold, an extrapericardial patch has been implanted by means of a video-thoracoscopic approach: a left subcostal incision is performed and the subdiaphragmatic extraperitoneal space is reached; a patch electrode is then introduced into the left pleural cavity by blunt dissection of the diaphragm. This patch is positioned under thoracoscopic control in contact to the left pericardial surface and fixed by single stitches sutures. The impulse generator is finally implanted into the subdiaphragmatic pocket. In all the patients the patch electrode configuration sufficiently decreased defibrillation thresholds. In one of the patients a stellectomy was thoracoscopically performed to treat the long QT syndrome which was the cause of the ventricular fibrillation episodes. Defibrillation thresholds were confirmed after 8 day and 2 months postoperatively. In conclusion, the thoracoscopic implantation of an extrapericardial patch has allowed a significant reduction of defibrillation thresholds, without recurring to a major surgical procedure.