Successfully escaping the pleura with the extra-vascular implantable cardioverter defibrillator lead: a case report

Background: Extra-vascular implantable cardioverter defibrillator (EV-ICD) is an emerging technique for ICD implantation with substernal lead placement. The system avoids the vasculature and can deliver anti-tachycardia and pause prevention pacing, with a generator size smaller than the existing subcutaneous device. While this device is now widely available, little is known about potential complications that may follow its implantation in real life context. Case summary: We report the case of a 46-year-old male with a history of non-ischaemic dilated cardiomyopathy, severely reduced left ventricular ejection fraction, and intravenous drug use who underwent EV-ICD implantation for primary prevention of sudden cardiac death. The device implantation was uncomplicated with initial satisfactory device parameters and fluoroscopic position. However, post-implant chest radiograph demonstrated lead dislodgement. Despite meticulous assessment on post-implantation CT, the exact position of the dislocated lead couldn't be determined with certainty. Lead revision was performed at 1 month following implantation, and fluoroscopic assessment at this time revealed lead movement synchronous with respiration, raising suspicion that the lead was intra-pleural. A sheath was repositioned over the dislocated lead and contrast injected. Contrast dispersion confirmed the intra-pleural positioning of the lead and was subsequently used as landmark for the appropriate substernal retunnelling of the lead. At most recent follow-up, lead position on chest radiograph and device parameters were satisfactory. Discussion: Extra-vascular implantable cardioverter defibrillator lead placement and dislodgement within the pleural space can follow apparently uncomplicated implantation. Both cine-imaging and contrast injection can be used for accurate assessment of the lead position relative to the pleura and help successful reimplantation.