Low Lateral Thoracic Site for Cardiac Implantable Electronic Device Implantation: A Viable Alternative in Patients with Limited Access Options After Infected Device Extraction

Background: Device reimplantation after extraction because of cardiac implantable electronic device (CIED) infection in pacemaker-dependent patients can be challenging in individuals with limited access options.

Objective: The purpose of this study was to describe a straightforward, low lateral thoracic implantation technique for patients with a patent axillary vein but unavailable bilateral pectoral sites.

Methods: Nine pacemaker-dependent patients (mean age 70 ± 13 years, 7 male) who underwent CIED extraction and low lateral thoracic reimplantation in whom bilateral pectoral sites were unavailable were included in the study.

Results: Extraction was performed a median of 10 (interquartile range [IQR] 8-13) days before CIED reimplantation (4 dual-chamber, 3 single-chamber, 2 cardiac resynchronization therapy). The new generator was implanted in the low lateral thoracic region ipsilateral to the extracted generator in 7 patients (78%) and contralateral in 2 patients (22%), via a subcutaneous pocket in 6 (67%) and submuscular pocket in 3 (33%). Median procedure duration was 85 (IQR 61-116) minutes, median fluoroscopy time was 7.2 (IQR 5.7-10.9), minutes and median fluoroscopy exposure was 26.0 (IQR 10.0-110.5) mGy. No acute complications occurred. Over median follow-up of 92 (IQR 31-131) days, 1 patient experienced right atrial lead dislodgment (122 days postimplantation) requiring lead revision. No patients experienced recurrent device infection.

Conclusion: In pacemaker-dependent patients with limited prepectoral and vascular access options, a low lateral thoracic implantation site is a viable alternative to surgical epicardial or femoral pacing systems. This simple implantation technique is a safe and effective option in selected patients who require a single-chamber, dual-chamber, or biventricular pacemaker or implantable cardioverter-defibrillator.