Associazione Nazionale Medici Cardiologi Ospedalieri

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CONGRESS ABSTRACT

CONGRESS ABSTRACT

A MIDDLE GROUND BETWEEN TRANSVENOUS AND SUBCUTANEOUS DEFIBRILLATION: EXTRAVASCULAR ICD IN A YOUNG HCM PATIENT WITH LEAD FAILURE

Santobuono Vincenzo Ezio Bari (Ba) – Cardiologia, Università Degli Studi Di Bari “Aldo Moro” | Barnaba Ivano Bari (Ba) – Cardiologia, Università Degli Studi “Aldo Moro” | Memeo Riccardo Bari (Ba) – Cardiologia Universitaria, Policlinico Di Bari | Armenise Francesca Bari (Ba) – Cardiologia, Universitaria Degli Studi Di Bari “Aldo Moro” | Caretto Pierpaolo Bari (Ba) – Cardiologia, Universitaria Degli Studi Di Bari “Aldo Moro” | Carella Maria Cristina Bari (Ba) – Cardiologia, Universitaria Degli Studi Di Bari “Aldo Moro” | Basile Paolo Castellaneta (Taranto) – Cardiologia, Po Occidentale “San Pio Da Pietralcina” Castellaneta – Asl Taranto | Lenoci Cosimo Daniele Bari (Ba) – Cardiologia, Università Degli Studi Di Bari “Aldo Moro” | Ciccone Marco Matteo Bari (Ba) – Cardiologia, Università Degli Studi Di Bari “Aldo Moro” | Guaricci Andrea Igoren Bari (Ba) – Cardiologia, Università Degli Studi Di Bari “Aldo Moro”

BACKGROUND: In hypertrophic cardiomyopathy (HCM), an implantable cardioverter-defibrillator (ICD) is a Class I recommendation according to ESC guidelines after resuscitated ventricular fibrillation. In young patients, however, decades of exposure to transvenous leads translate into a meaningful risk of lead failure, venous obstruction and infections. Subcutaneous ICDs avoid the vascular system and cardiac chambers but still cannot deliver antitachycardia pacing (ATP). The extravascular ICD (EV-ICD) places the lead in the substernal space, aiming to combine vascular sparing with ATP. CASE PRESENTATION: A 25-year-old man with HCM suffered an exercise-related cardiac arrest in 2014 (documented VF) and received a single-chamber transvenous ICD for secondary prevention. He presented with shocks occurring during sleep. Device interrogation showed five inappropriate shocks due to intermittent ventricular lead noise, and an elective replacement indicator (likely triggered by the shocks), while sensing and impedance were otherwise within range.Echocardiography confirmed severe septal hypertrophy (up to 28 mm), preserved ejection fraction (58%) with reduced global longitudinal strain (−10.9%), chordal systolic anterior motion and no significant intraventricular pressure gradient. A previously reported mobile mass adherent to the lead at the tricuspid annulus had remained clinically silent with a negative infectious work-up. Given recurrent inappropriate therapies, young age and the desire to limit long-term endovascular burden, the transvenous system was removed and the lead extracted. An EV-ICD (Aurora, Medtronic) was then implanted with a substernal lead and a left lateral generator pocket. Induced VF was promptly detected and terminated with a 30-J shock. The patient was discharged three days later and remained event-free with normal device function at early and mid-term follow-up. CONCLUSIONS: In selected young patients with strong ICD indications and transvenous lead complications, EV-ICD can represent a pragmatic compromise, reducing intravascular hardware while preserving defibrillation efficacy and ATP capability