Four devices, one solution: gold-coated cardiac resynchronization therapy with a defibrillator in a patient with...

Titanium hypersensitivity is a rare but important cause of recurrent complications in patients with cardiac implantable electronic devices (CIEDs). Despite titanium's biocompatibility, hypersensitivity reactions can mimic device infection, leading to repeated device removals before diagnosis.

We report the management of a 67-year-old man with non-ischemic cardiomyopathy who presented to our institution after three failed cardiac resynchronization therapy with defibrillator (CRT-D) implantations over three years, each complicated by wound dehiscence and infection-like symptoms. The patient had been diagnosed with titanium hypersensitivity previously but prior attempts to mitigate exposure, including a Gore-Tex-wrapped device were unsuccessful. Therefore, a custom gold-plated CRT-D was obtained under U.S. Food and Drug Administration (FDA) compassionate use provisions. The gold-plated CRT-D was implanted via a right-sided approach. At one-year follow-up, the surgical site remained well-healed with no recurrent complications or device-related discomfort and left ventricular ejection fraction (LVEF) improved from 29% to 50%.

This case underscores the diagnostic challenges of titanium allergy, the limitations of conventional management, and the value of multidisciplinary collaboration to navigate regulatory pathways and deliver durable, patient-specific solutions.