Nonthoracotomy leads have become standard for implantable cardioverter-defibrillators (ICD) because of low perioperative morbidity, mortality, and expense. Reported increases in defibrillation thresholds (DFTs) with these lead systems, however, have raised the possibility of an eventual loss of defibrillation efficacy. The mechanism of this increase is unknown. In contrast, defibrillation efficacy of traditional epicardial lead systems has been demonstrated to remain relatively stable. In the present study, we examined the implantation and chronic DFTs in 45 patients with a hybrid system (a high right atrial coil and an extrapericardial patch) that combines elements from both the thoracotomy and nonthoracotomy approach. The mean threshold increased from 11.7 +/- 3.0 to 15.8 +/- 10.0 J (p < 0.001) and mean impedance increased from 37.0 +/- 7.7 to 48.8 +/- 9.0 ohms (p < 0.0001). There was a marked (> or = 10 J) increase in DFT in 11 patients (24%) including 4 who required reoperation to obtain an adequate safety margin. The increase in DFT was unrelated to any of the analyzed variables. We conclude that the presence of an extrapericardial patch does not prevent the increase in DFT reported with nonthoracotomy lead systems. This increase is unpredictable and occurs in almost 25% of patients.