Excerpt

A very thin 30-year-old patient with hypertrophic cardiomyopathy and secondary prevention ICD initially implanted 20 years ago, multiple episodes of ventricular tachycardia requiring ATP, developed multiple device pocket erosions in spite of generator placement in the retro-pectoral plane (Fig. 1a). Pocket cultures were negative; however, a local infection could not be excluded. In 2012, he had trans-atrial lead implantation via mini-thoracotomy and the device tunneled to the abdominal wall [1]. In 2020, he underwent generator replacement with inadvertent lead dislodgment. Due to surgical placement, lead reposition was not possible. Extremely scarred tissue in both sub-clavicular areas precluded re-implantation. A new procedure was performed using a low-pectoral incision and a low-axillary venous puncture with the abduction of the left arm (Fig. 1b, c). A 65-cm single-coil active-fixation defibrillator lead (Plexa ProMRI, Biotronik) was advanced to the right ventricular apex where lead parameters were confirmed; it was then secured to the pectoral muscle. A second lateral incision along the border of the latissimus dorsi was made, and an intermuscular pocket between the latissimus dorsi and serratus anterior was created, in a higher location than that used for intermuscular S-ICD implant. This location was preferred due to a better shocking-vector configuration. The lead was tunneled to the pocket and connected to the generator (Intica 5VR-T, Biotronik). X-ray image depicts final lead and generator position (Fig. 1d). DFT testing was successful at 20 J. The generator was not noticeable after closing both incisions (Fig 1e). There were no complications at 3-month follow-up (Fig. 1f). There are reports of low-axillary venous access but generator placement has been confined to both retro-pectoral and low-lateral subcutaneous plane [2]. It is important to note that larger patients may need longer leads, being the longest lead currently available 97 cm in length. To the best of our knowledge, this is the first description of this approach and highlights the feasibility of performing transvenous implants with concomitant postero-lateral device placement using an intermuscular device pocket for larger generators such as ICD and CRT-D in patients with low BMI, patent venous anatomy and conditions in which it is preferred to have pacing capabilities.

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