Background: In patients with limited venous access the extravascular implantable cardioverter defibrillator (ICD) system represents a good alternative to transvenous ICD or subcutaneous ICD. Extravascular devices, which can deliver antitachycardia pacing (ATP) are still under evaluation. We describe a successful alternative case of ATP-therapy through an extravascular System in an adult patient.

Case Report: A 61-year-old male patient was implanted with a complete extravascular ICD system due to bilateral occluded subclavian veins after radiation for bronchogenic carcinoma and the indication for ATP therapy because of recurrent ventricular tachycardia (VT). The procedure was performed under general anesthesia, a left antero-lateral mini thoracotomy was used to access the pericardium. A transvenous single-coil right ventricular (RV) ICD lead was introduced in the pericardium and positioned underneath the infero-basal RV bottom. A left ventricular (LV) bipolar sutureless epicardial pacing lead was screwed antero-lateral into the LV wall, both leads were subcutaneously tunneled into the device pocket and connected to the DF1 and IS1 connector of a single chamber ICD device, which was placed in a left infraclavicular submuscular pocket. No peri-operative complications occurred. Five weeks after discharge, the patient was readmitted for recurrent slow VTs. Based on the ICD storage, these slow VTs were successfully terminated by cumulative twenty-one ATP therapies via the epicardial left ventricular bipolar pacing lead. No ICD shock therapy was documented. The patient was under therapy with amiodaron and beta blocker and underwent a successful VT ablation.

Conclusion: This case report shows that a complete extravascular ICD system including a bipolar sensing and pacing LV lead as well as a transvenous single-coil ICD lead can successfully deliver multiple ATP therapies. This minimally invasive technique is a safe and feasible alternative in patients with limited vascular access. We also stress the importance of the involvement of a heart team in the treatment of these complex cases.