Supraspinatus pocket: An alternative pacemaker location for patients with no prepectoral access

Case report We report the case of a 55-year-old man with a history of oral cancer treated by surgery and radiotherapy who presented with recurrent syncope due to sinus node dysfunction and complete atrioventricular (AV) block after extensive neck and face reconstructive surgery. Surgeons had previously removed all pectoral muscles for facial reconstruction. During this reconstructive surgery, the patient experienced cardiac asystoles due to carotid sinus hypersensitivity secondary to vagus nerve injury. After the surgery, repeated 15to 30-second episodes of asystole due to sinus dysfunction and complete AV block occurred in the intensive care unit, requiring permanent pacing. However, because of the removal of all pectoral muscles and skin damage secondary to recent surgery and previous radiation therapy, the implantation of the generator in the standard subclavicular position was not possible. We thus decided to implant a singlechamber pacemaker in a right supraspinatus subcutaneous pocket. The patient was positioned in left decubitus to allow access to the right supraspinatus muscle, and a single ventricular lead was introduced through the right internal jugular vein (details in Supplementary Figure 1). We then performed a subcutaneous tunneling of the lead between the jugular access and the supraspinatus pocket and connected the ventricular lead to a KORA SR 100 generator (Sorin Group) (Figure 1). The can was inserted in the subcutaneous pocket and fixed to the muscle. Six months later, the patient did not feel any pain, the scar was clean, and the position of