CONGRESS ABSTRACT

A 43-year-old man was referred to our center for complete exposure of ICD pocket. The generator was fully exposed in the right prepectoral–axillary region, with total exposure of the lead electrodes up to the fixation sleeves. The patient had a history of double-outlet right ventricle surgically corrected in 1981, with residual ventricular septal defect and mild left-to-right shunt atrial septal defect (ASD). In 1982, due to complete atrioventricular block, a dual-chamber pacemaker was implanted in the left prepectoral region.Because of recurrent sustained ventricular tachycardias an ICD was subsequently implanted in the right prepectoral region, with removal of the left-sided pacemaker and abandonment of the ventricular pacing lead. In July 2019, the patient was admitted for pocket erosion and underwent generator repositioning in the right subpectoral region. In October 2019, recurrence of pocket erosion occurred, the TEE showing vegetations on both atrial and ventricular leads. Device extraction was proposed but declined.In May 2023, the patient presented with ICD shock during ventricular tachycardia, associated with electrode exposure and purulent discharge, and was referred to our institution. TTE revealed an ejection fraction of 38%. TEE and intracardiac echocardiography confirmed lead-related endocarditis with multiple vegetations. Venography demonstrated left-sided venous patency and right subclavian vein occlusion. Cardiac CT confirmed VSD, ASD (ostium secundum), and subclavian vein strictures. After heart team discussion, transvenous lead extraction was attempted on September 12, 2023. Due to an unresolvable adhesion at the superior vena cava, surgical extraction was subsequently required. A CRT-P device was implanted with epicardial leads in the left prepectoral region, along with reconstruction of the right atrioventricular junction and ASD closure. On October 4, a subcutaneous ICD was implanted.The patient was discharged afebrile but was readmitted in November 2023 with CRT-P pocket erosion and fever. Given the high infectious risk, a leadless VDD pacemaker was implanted after electroanatomic mapping of the right ventricle because of a dacron patch on IVS, and the CRT-P generator was removed and an S-ICD implanted. This case highlights the complexity of device-related complications in young patients and emphasizes the importance of a multidisciplinary, integrated approach to optimize outcomes