AIMS: The optimal implantable cardioverter defibrillator (ICD) system implant technique has not yet been defined in young patients and those with congenital heart disease (CHD). We describe our 5-year experience with epicardial pacing/sensing leads secured on the left cardiac chambers and a pleural defibrillation lead insertion along the third intercostal space. METHODS AND RESULTS: Implantable cardioverter defibrillator systems were implanted in 15 children and adolescents (age: 2.9-20.0 years) for primary (n = 11) or secondary (n = 4) prevention. Underlying CHD were hypertrophic (n = 10) or dilative cardiomyopathies (n = 2), primary electrical diseases (n = 2), and transposition of the great arteries (n = 1). Devices were placed in the rectus sheath (n = 5), or within the diaphragm (n = 10). Median defibrillation threshold at implant was 15 J (range: 10-25). During 5 years of follow-up (median: 22 months), nine appropriate and two inappropriate ICD discharges occurred. Four system revisions were required due to device recall, pleural lead dislodgement, epicardial lead fracture, and insulation break. Twelve months after the implantation, defibrillation threshold testing demonstrated stable thresholds of <or=20 J in five patients. CONCLUSION: Our 5-year experience demonstrates the efficacy of epicardial and pleural lead ICD systems. Inappropriate shocks and lead failures are observed as in other ICD systems. It represents an alternative implant technique for young and active patients and those without venous access.