fig1 through 29 of the drawings depict various preferred embodiments of the present invention for purposes of illustration only . one skilled in the art will readily recognize from the following discussion that alternative embodiments of the structures and methods illustrated herein may be employed without departing from the principles of the invention described herein . a defibrillator installed by the method of the present invention is shown in fig1 and 2 . fig3 through 6 show various shapes of electrodes that may be used . the preferred embodiment of the method of installing the defibrillator is detailed in fig7 through 15 . fig1 and 17 show a defibrillator installed pursuant to an alternative embodiment of the method of the present invention , and fig1 through 29 detail that alternative embodiment . in fig1 the defibrillator is shown after implantation , with the electrodes 40 and 42 located on the anterior and posterior surfaces of the heart respectively . the electrodes are held in place by two cannulae , or catheter sections , 44 and 46 , which are in turn held by two fastening buttons 48 and 50 which are sewn to the pericardium or surrounding connective tissue . the electrode leads 52 and 54 are attached to the implanted defibrillator module 56 . the electrodes may be of various shapes , as shown in fig3 through 6 . in the preferred embodiment , the electrode is preconfigured as a spiral in order to increase the contact area and thus simulate the function of a paddle electrode . in fig3 the spiral is a conical one which does not lie in a single plane but spirals upward as it spirals inward . fig4 is a top view of this electrode , taken along line 4 -- 4 in fig3 . this three - dimensional coil gives the electrode a spring effect between the heart surface and the pericardium which tends to keep the electrode in place . alternatively , a flat spiral shape may be used for the electrode . in fig5 a flat round spiral electrode is shown . in fig6 an electrode having a &# 34 ; square spiral &# 34 ; shape is shown . fig7 shows the first step of the preferred embodiment of the method of the present invention . an incision 58 is made in the upper abdominal wall of the patient ; the tissues between this incision 58 and the pericardium of the patient are separated digitally by spreading of the surgeon &# 39 ; s fingers , and another incision 60 is made in the pericardium . the cannulus 46 is inserted into the pericardial sac through these incisions . the preconfigured electrode 42 is then inserted into the pericardium through the cannulus 46 to the posterior of the heart , as shown in fig8 . to increase the ease of insertion of the electrode , a stylet 62 is inserted into the electrode to straighten it before insertion . the distal end of the electrode 42 is extended beyond the end of the cannulus 46 , as shown in fig9 and the stylet 62 is then removed , allowing the electrode 42 to assume its preconfigured shape . the resulting position is shown in fig1 . the other cannulus 44 and corresponding electrode 40 is inserted in the same manner , but on the opposite side ( anterior ) of the heart , resulting in the position shown in fig1 . electrode leads 52 and 54 extend from the ends of the cannulae 44 and 46 . fastening buttons 48 and 50 are then placed on the cannulae 44 and 46 , as shown in fig1 , and sewn to the pericardium or surrounding connective tissue with sutures 66 . a detailed view of a fastening button is shown in fig1 ; it contains a channel 64 through which the cannulus passes , and a crimping ring 68 which is made of metal . after the fastening buttons 48 and 50 are sewn in place , the cannulae 44 and 46 are manipulated until the electrodes 40 and 42 are located in the desired positions , and the crimping rings 68 are then crimped with pliers or some other tool such that the cannulae 44 and 46 are fixed in the desired positions . as mentioned above , a fluoroscope may also be used to view the electrodes for assistance in locating them where desired . next , the excess portions of the cannulae 44 and 46 which extend beyond the heart and the fastening buttons 48 and 50 are removed , as shown in fig1 . a cutting tool 70 is used to cut the cannulae 44 and 46 without cutting the electrode leads 52 and 54 . cutting tool 70 is shown in detail in fig1 . it includes a hinged cylindrical body comprised of stationary piece 72 and movable piece 74 , which is hinged near the proximate end of cutting tool 70 . inside at the distal end is cutting edge 76 . in practice , movable piece 74 is opened and cutting tool 70 is slid over one of the cannulae until the distal end is proximate to the fastening button , and the movable piece 74 is then closed . this pins the cannulus in the cutting tool 70 so that it may be cut by cutting edge 76 , which extends far enough into the center of cutting tool 70 to cut the cannulus but not the electrode lead . cutting tool 70 is then rotated to score the cannulus all the way around its circumference . in fig1 , cutting tool 70 is shown in place on cannulus 46 , next to fastening button 50 , with electrode lead 54 extending ; the excess portion of cannulus 44 has already been removed , leaving electrode lead 52 . the arrow shows that cutting tool 70 is being rotated . after the excess portions of cannulae 44 and 46 have been removed , electrode leads 52 and 54 may be connected to the defibrillator module 56 and the incision in the body closed . in using this method , it is also possible to use electrodes which do not incorporate stylets . in this case the spiral is straightened manually and then inserted into the cannula , which keeps the electrode straight until it emerges from the distal end of the cannula , at which point it again assumes a spiral shape . fig1 and 17 show a front and side view respectively of an alternative embodiment of the present invention . electrodes 40 and 42 are connected to defibrillator module 56 through electrode leads 52 and 54 . the electrodes may be of the same shapes as in the preferred embodiment . however , there are no cannulae or fastening buttons in this embodiment . fig1 shows the first step of making an incision 58 in the upper abdominal wall and inserting a forceps tool 78 therein . the forceps tool 78 has a clamping body 80 on which is mounted a channel portion 82 . within the channel portion 82 is a hollow stylet 84 with a proximal end piece 81 . stylet 84 may have a pointed distal end 83 as shown in fig2 , or a flat end 85 which is beveled all the way around , as shown in fig2 . the stylet 84 is slidable within the channel portion 82 , and the distal end 83 or 85 is limited to extending no more than approximately 1 centimeter beyond the distal end of the channel portion 82 by the end piece 81 . the clamping body 80 is used to grasp the pericardium and &# 34 ; tent &# 34 ; it by lifting it away from the heart surface , and the distal end of the stylet 84 is then advanced through the channel portion 82 and used to puncture the pericardium , as shown in fig1 . this &# 34 ; tenting &# 34 ; prevents the user from accidentally puncturing the heart itself while the pericardium is punctured , since the distance that the end of the stylet 84 may extend beyond the channel portion 82 is limited by end piece 81 . if the end of the stylet 84 is the pointed end 83 of fig2 , the puncture may be made by simply advancing the stylet 84 , as shown by the arrow in fig2 . on the other hand , if the stylet 84 has the beveled end 85 of fig2 , it may be necessary to rotate the stylet 84 as shown by the arrow in fig2 . fig2 shows an end view of the channel portion 82 , with the stylet 84 within , taken along line 20 -- 20 in fig1 . a guide wire 86 is then advanced through the stylet 84 , as shown in fig2 ; in fig2 the wire 86 has been advanced so that its distal end is posterior to the heart . once the guide wire is in place , the stylet 84 is removed by retracting it , as shown by the arrow in fig2 ; the wire 86 may then be laterally removed from the channel portion 82 of the forceps tool 78 , as shown in fig2 and 25 , and the forceps tool 78 is itself removed , leaving only the guide wire 86 in place . a two piece catheter is then advanced into the pericardium , as shown in fig2 . this catheter is composed of an internal catheter 88 with a tapered tip and an outer catheter body 90 . as the internal catheter 88 is advanced , the tapered tip opens the incisions enough to permit passage of the outer catheter body 90 . once the outer catheter body 90 is in place , the guide wire 86 and inner catheter 88 may be . removed , as shown in fig2 . as above , here the placement shown is posterior to the heart . now electrode 42 may be inserted through catheter 90 , as shown in fig2 . as in the prior embodiment , a stylet 92 may be used to straighten out the preconfigured electrode 42 to permit easier insertion . if the electrode 42 is to be placed posterior to the heart by going over the shoulder as shown here , the stylet 92 may be somewhat flexible so that the electrode 42 can be pushed as far as the distal end of catheter 90 with the stylet 92 in place . then , as the electrode 42 is advanced further , it simultaneously exits catheter 90 and assumes its preconfigured shape . finally , the stylet 92 and catheter 90 are removed , leaving the electrode 42 in place , as shown in fig2 . the electrode lead 54 is connected to the defibrillator module 56 . the other electrode 52 is inserted by the same method , but anterior to the heart . ( alternatively , the electrodes may be placed on opposite lateral sides of the heart .) the placing of the electrode 42 posterior to the heart by going over the shoulder of the heart helps to prevent migration . if more security is desired , the electrodes may be sutured in place , or small anchors may be added to the distal ends of the electrodes to anchor them . from the above description , it will be apparent that the invention disclosed herein provides a novel and advantageous method for implanting an automatic defibrillator . the foregoing discussion discloses and describes merely exemplary methods and embodiments of the present invention . as will be understood by those familiar with the art , the invention may be embodied in other specific forms without departing from the spirit or essential characteristics thereof . for example , other shapes of electrodes may be used , and they may be located in other positions , as long as migration is prevented . accordingly , the disclosure of the present invention is intended to be illustrative , but not limiting , of the scope of the invention , which is set forth in the following claims .
a method and apparatus for implanting an automatic implantable defibrillator without the need for major surgery is disclosed . preconfigured electrodes are straightened by the use of a stylet or by the surrounding catheter and inserted into the intrapericardial space through catheters . the catheters may be removed or may be left in place and attached to the pericardium or surrounding tissue to hold the electrodes in place .