First Reported Extravascular-ICD Insertion in a Patient With Prior Sternotomy for Valvular Surgery

The extravascular implantable cardioverter-defibrillator (EV-ICD) is a novel nontransvenous system designed to prevent sudden cardiac death while avoiding complications associated with transvenous leads. Insertion after prior sternotomy is currently considered contraindicated and to our knowledge has not previously been reported.

A 68-year-old man with prior Bentall procedure developed anthracycline-induced cardiomyopathy requiring ICD insertion for primary prevention. The need to preserve venous access and failed subcutaneous ICD screening limited the available options. Preprocedural imaging demonstrated a measurable retrosternal space without significant adhesions. EV-ICD insertion was successfully performed without resistance during retrosternal tunneling, and the lead was appropriately positioned. Defibrillation testing was successful, and the postoperative course was uneventful.

Median sternotomy may result in variable retrosternal adhesions and anatomical changes. In this setting, insertion of a retrosternal defibrillation lead requires careful anatomical assessment and meticulous technique.

EV-ICD insertion may be feasible in carefully selected patients with prior sternotomy.