3.2.1 Preoperative Preparation (Department of CARDIOLOGY, 2018)

1. Patient Evaluation: Review medical history (focus on cardiac health and arrhythmia risks) and obtain informed consent. Conduct blood tests, ECG, chest X-ray, and echocardiogram. Administer antibiotic prophylaxis.

2. Equipment Preparation: Sterilize and prepare ICD device, leads, X-ray fluoroscopy, external defibrillator, and anesthesia setup.

3. Patient Positioning and Monitoring: Position patient supine with left arm abducted for chest access. Perform sterile preparation and administer IV antibiotics.

3.2.2 Venous Access and Lead Placement (Implantable Cardioverter-defibrillators (ICDs) - Mayo Clinic,2023)

1. Venous Access: Use ultrasound or anatomical landmarks to access the subclavian or cephalic vein, inserting an introducer sheath for lead placement.

2. Incision and Pocket Creation: Make a 5–8 cm incision in the left infraclavicular area. Create a subcutaneous pocket for the ICD generator above the pectoralis major muscle, ensuring minimal bleeding.

3. Electrode Positioning: Advance defibrillation lead into the right ventricle under fluoroscopic guidance, testing fixation and function. Additional leads are placed for dual-chamber/biventricular pacing if required.

3.2.3 Lead Fixation and Device Connection (Implantable Cardioverter-defibrillators (ICDs) - Mayo Clinic,2023)

• Tunnel leads to the subcutaneous pocket and connect to the ICD generator, coiling excess length to prevent tension and dislodgement.

3.2.4 Device Programming and Testing (Implantable Cardioverter-defibrillators (ICDs) - Mayo Clinic,2023)

• Program pacing, sensing, and shock thresholds. Afterwhich, conduct initial testing for sensing, pacing, and defibrillation thresholds, adjusting settings as needed.

3.2.5 Closure and Postoperative Care (Department of CARDIOLOGY, 2018)

1. Incision Closure: Irrigate, apply antibiotic solution, and close incision. Document device and lead specifications.

2. Monitoring: Observe in recovery with ECG and ICD function monitoring. Perform a postoperative chest X-ray

3. Patient Education and Follow-Up: Provide wound care and activity instructions. Schedule follow-up for wound assessment and device function review within 1-2 weeks.

3.3.1 Preoperative Preparation (Department of CARDIOLOGY, 2018)

1. Patient Evaluation: Review cardiac arrhythmia history and educate patient on risks and benefits. Obtain informed consent and conduct blood tests, ECG, and chest X-ray. Administer prophylactic antibiotics.

2. Equipment Preparation: Prepare sterile S-ICD device, subcutaneous electrode, tunneling tools, and defibrillator testing equipment. Ensure monitoring equipment is functional.

3. Patient Positioning and Monitoring: Position patient supine with left arm abducted. Sterilize and drape chest wall; administer IV antibiotics and set up ECG, BP, and oxygen monitoring.

3.3.2 Incision and Pocket Creation (Lewis & Gold, 2016)

1. Primary Incision and Pocket: Create a 5-7 cm incision at the left mid-axillary line, then a subcutaneous pocket for the S-ICD generator. Adjust pocket depth for secure placement.

2. Electrode Incision and Tunneling: Make a small incision near the xiphoid process and tunnel the electrode from primary incision site along the parasternal area up to the manubrium, ensuring optimal placement for sensing and defibrillation.

3.3.3 Electrode Positioning and Testing (Implantable Cardioverter-defibrillators (ICDs) - Mayo Clinic,2023)

• Position electrode and perform intraoperative testing to confirm sensing function and QRS amplitude. Adjust electrode if needed for effective defibrillation.

3.3.4 Device Connection and Pocket Closure (Implantable Cardioverter-defibrillators (ICDs) - Mayo Clinic,2023)

• Connect electrode to S-ICD generator, place in subcutaneous pocket, and coil excess electrode to reduce tension. Irrigate with saline and antibiotic solution.

3.3.5 Device Programming and Testing (Implantable Cardioverter-defibrillators (ICDs) - Mayo Clinic,2023)

• Program the S-ICD for personalized therapy, setting arrhythmia detection parameters. Perform defibrillation threshold (DFT) testing with low-energy shocks to confirm detection and treatment effectiveness.

3.3.6 Closure and Postoperative Care (Department of CARDIOLOGY, 2018)

1. Incision Closure: Irrigate pocket with saline, close incisions with absorbable sutures for deeper layers, and apply a sterile dressing.

2. Monitoring: Observe patient postoperatively with ECG and ICD monitoring. Perform chest X-ray to confirm electrode position and check for complications.

3. Patient Education and Follow-Up: Provide instructions for wound care and movement restrictions. Schedule follow-up within 1-2 weeks for wound assessment and device interrogation to adjust settings as needed.