First Surgical Implantation of an Extravascular-ICD Lead in a Patient With Prior Sternotomy in the United States

Introduction/Background:

Extravascular implantable cardioverter defibrillator (EV-ICD) implantation is contraindicated in patients who have had a prior sternotomy. We describe the surgical implantation of an EV-ICD lead in a patient with Ebstein’s anomaly during repeat tricuspid valve (TV) surgery and clinical sustained ventricular tachycardia (VT).

Description:

A 49-year-old man with a history of Ebstein’s anomaly and TV repair without mobilization of posterior and septal leaflets presented with heart failure symptoms. He was in atrial flutter (AFL) with uncontrolled ventricular rates. Echocardiography showed Ebstein’s anomaly with torrential TV regurgitation. TV surgery was planned, but sustained VT occurred while awaiting the operation. Electrophysiology and cardiothoracic surgery teams jointly planned the treatment of AFL and VT. The electrophysiologist performed a preoperative AFL cavotricuspid isthmus ablation. Then an intraoperative right atrial maze procedure, redo TV replacement due to inadequate leaflets from prior repair, plication of the atrialized right ventricle, and left internal mammary artery to left anterior descending coronary artery grafting were completed. To avoid placing a lead across the new TV, an EV-ICD lead was sutured to the anterior surface of the right ventricle. Lead testing showed excellent sensing with an R wave of 4.0 mV and no P wave oversensing. Postoperative heart block was treated with a permanent pacemaker with atrial and coronary sinus branch leads to avoid crossing the TV and desynchronizing the left ventricle.

Discussion:

This is the first case in the United States of a surgically placed EV-ICD lead in a patient with a prior sternotomy. It highlights the importance of collaboration between electrophysiology and cardiothoracic surgery in the innovative treatment of complex arrhythmias in patients with congenital heart disease.