**6.6 Internal cardioverter defibrillator (ICD) placement**

 Those with risk factors of sudden cardiac death and history of sustained ventricular tachycardia/fibrillation benefit from placement of internal cardioverter defibrillator (ICD) [ 19 ].

 Several strategies and techniques have been proposed for placement of ICD such as endovenous, subcutaneous [ 20 ] and epicardial ( **Figure 14A** and **B** ). If the patient did not have ICD prior to surgery, and meets the criteria, our practice is to place the ICD prior to hospital discharge after septal myectomy. In children, the preference has been to perform concomitant myectomy with epicardial ICD placement through the sternotomy incision.

#### **Figure 14.**

 *In children who needed an internal cardioverter defibrillator placement, the procedure is usually done after completion of the myectomy where an epicardial system is placed and the defibrillator coil (visualized in figure A) is secured to the pericardium below the phrenic nerve, while the sensing epicardial leads are secured to the epicardial surface of the right ventricle (seen in figure B) and the device is placed in the epigastric area behind the rectus abdominis muscle.* 
