CONGRESS ABSTRACT

Abstract The subcutaneous implantable cardioverter-defibrillator (S-ICD) represents an effective alternative to transvenous systems for the prevention of sudden cardiac death, particularly in patients with challenging vascular access or anatomical anomalies. We report the successful implantation of an S-ICD in a patient with situs inversus totalis, a condition with unique technical challenges. Case Presentation A 54-year-old female with known situs inversus totalis and no prior cardiac history was admitted due to chest pain. Followed by a diagnosis of NSTEMI, successfully treated with a DES implantation. TTE showed severe hypokinesia of the left ventricle with an EF of 28%. Given the rare combination of situs inversus totalis and SCA, detailed assessment of anatomical implications was essential. The atypical anatomy rendered a S-ICD preferable, considering the young age, the absence of pacing indications and the increased risk of complications with transvenous ICD. Methods A preoperative thoracic CT revealed dextrocardia with the apex directed laterally to the right, a left-sided aortic arch, and mirrored positions of both vena cava, that required a reversed implant strategy compared to standard left-sided S-ICD procedures. Pre-implantation ECG screening was performed using a mirrored electrode configuration to replicate the electrical axis pathway. All three sensing vectors were deemed appropriate, supporting the feasibility of S-ICD implantation in this context. Using a standard two-incision technique, the generator pocket was created in the right lateral thoracic, between latissimus dorsi and serratus anterior muscles in the right lateral thoracic region, and the lead tunneled along the right parasternal line, mirroring the conventional left-sided implantation. Results The implantation was successful without intraoperative complications. The result of PRAETORIAN score (30) fell within the low-risk category and suggesting an optimal shock vector. The patient tolerated the procedure well, and was discharged in good condition. Conclusion S-ICD implantation in patients with situs inversus is both feasible and safe when preceded by detailed imaging and tailored procedural planning, and represents a significant advantage by avoiding the risks associated with transvenous systems in such anatomical variants Thus, this approach should be considered when transvenous ICD implantation poses elevated risks or technical difficulties about non-standard implantations