A left subcostal surgical approach was used to implant an automatic implantable cardioverter defibrillator (AICD) in 48 patients with a history of nonfatal cardiac arrest or documented ventricular tachycardia/fibrillation. Electrophysiologic studies before surgery yielded induction of monomorphic or polymorphic ventricular tachycardia in 40 patients, whereas 8 were noninducible. Mean (+/- standard deviation) age was 58 +/- 12 years. Mean ejection fraction was 33 +/- 16%. Thirty patients (63%) had documented coronary artery disease; 14 patients (29%) had previous coronary bypass surgery. The mean intraoperative defibrillation threshold was 13.8 +/- 6.6 J. In 6 patients, an adjunctive right minithoracotomy was used to position 1 patch over the right atrium and thus optimize the defibrillation threshold. Patients with prior exposure to amiodarone and previous coronary bypass surgery had higher defibrillation thresholds at implantation. Two perioperative deaths occurred. There were no infections. Long-term follow-up yielded a 1- and 5-year survival of 0.88 and 0.58, respectively, and a freedom from sudden cardiac death of 1.0 and 0.97, respectively. The nonthoracotomy, left subcostal surgical approach is safe and effective, provides adequate defibrillation thresholds in most patients, and yields long-term survival comparable to other implantation techniques.