A case report of pre-implantation feasibility test for combining leadless pacemaker and subcutaneous implantable cardioverter-defibrillator in adult congenital heart disease

New cardiac implantable electronic devices (CIEDs), such as leadless pacemakers and subcutaneous implantable cardioverter defibrillators (S-ICDs), are being used in patients with adult congenital heart disease. The selection of CIEDs often requires careful consideration due to technical challenges posed by a unique heart structure. A 27-year-old man following a surgical tetralogy of Fallot (TOF) repair developed non-sustained ventricular tachycardia, sick sinus syndrome, and complete atrioventricular block. He had a history of recurrent bacteremia. We discussed the use of a combination of leadless pacemaker and S-ICD as a non-transvenous CIED after considering the infection risk and decided to select the appropriate CIED after a pre-implantation test. Ventricular tachycardia was not induced in the electrophysiological study. Although he did not need an ICD at that point, patients after TOF repair are at a high risk for ventricular tachycardia later in life. We measured the local pacing threshold and R-wave amplitude and performed an S-ICD screening for paced-QRS. Finally, we implanted a leadless pacemaker safely with the option to add an S-ICD if needed. A pre-implantation test could help future decisions regarding combinations of leadless pacemakers with S-ICDs in patients with adult congenital heart disease.

Learning objectives: The appropriate selection of a cardiac implantable electronic device (CIED) in patients with adult congenital heart disease requires careful consideration. The pre-implantation feasibility test for combining a leadless pacemaker (LP) and a subcutaneous implantable cardioverter defibrillator aided decision-making in CIED selection and safe LP implantation procedure in the unique heart structure.