An incision was made and the right sided generator pocket was created, bleeding was sought and appropriate areas were cauterized. We used a tunneling tool and brought the RV ICD lead from the right pocket into the left. The LV lead was freed up in the right sided pocket and had enough length to reach RA and LV leads were tunneled over the left sided pocket and connected to the device.

The device was placed in Tyrx pouch and placed in the left sided pocket and a single layer Vicryl 2-0 sutures were placed in the SQ plane and DFT testing was performed in multiple configurations. The DFT testing was unsuccessful requiring external rescue multiple times. The RV lead was repositioned in the apex and DFT were tested again in multiple configurations and was unsuccessful.

We then proceeded with the left subclavian venous access using a micropuncture needle and seldinger technique and a 9 Fr sheath was placed. Using a JR4 and KA-2 diagnostic catheters along with Wooley wire and Glide wire, injection of contrast dye, we were able to cannulate the Azygos vein, however were unable to advanced the wire further and could not successfully access the vein.

We then re-prepped the patient and positioned her in the right lateral position. We made an incision in the left anterior axillary line after infiltration of 1% Lidocaine. The incision was extended down the fascia and tunneling tool was used to tunnel to the posterior paraspinal region. A SQ coil was then placed using a peel away sheath and the peel away sheath was slit and removed. The coil was then tied down to the fascia using 0-Ticron. We then tunneled the SQ coil back into the ICD pocket and connected it to the high voltage splitter adapter. The lead adapter was then connected to the device and the device was placed in a Tyrx pouch. The pocket was flushed multiple times during the procedure using antibiotic solution. DFT testing was successful.

During pocket closure, there was a noise/clatter on the RV coil of the ICD lead. The pocket was opened again and the lead disconnected from high voltage adapter. Ticron sutures on RV lead were cut and removed. Using a straight stylet, the screw on the ICD lead was retracted and lead repositioned in the RV apex. The ICD lead was reconnected to the ICD using the adapter. Pocket was flushed again and device was placed in the Tyrx pouch and tied down using 0-Ticron. The pocket was closed and DFT testing was repeated and it was successful.

Thank you!