S4482 Dual Implantable Electronic Device Therapy and Pyloroplasty in the Setting of Cyclic Vomiting Syndrome With Superimposed Gastroparesis

Introduction: Gastroparesis (GP) and cyclic vomiting syndrome (CVS) are distinct conditions that present with nausea, vomiting, and abdominal pain. Gastric electrical stimulation (GES) is a treatment indicated for medically refractory GP. Evidence regarding the safety and efficacy of GES when there is a pre-existing implantable electronic device (dual-IED) is limited. We present a case of successful GES implantation in a patient with an automatic implantable cardioverter-defibrillator (AICD). Case Description: A 44-year-old woman with ventricular arrhythmia controlled with an AICD, long QT syndrome, and CVS presented for evaluation of superimposed post-viral GP. After a COVID-19 infection in 2022, vomiting episodes intensified from episodic and once yearly to multiple times daily. The patient was only able to tolerate a liquid diet and lost significant weight. A gastric emptying study showed 39% retention at 4 hours and delayed gastric emptying (T1/2 = 205 min). Given contraindications to corrected QT interval–prolonging agents, and refractoriness to other pharmacotherapies and diet, robotic Enterra® Therapy placement and pyloroplasty were performed. The GES device was implanted on the side contralateral to the AICD, and impedance was set to 475 Ω. Device placement was confirmed with fluoroscopy. At 8 months post-procedure, the patient was on a regular diet with significantly improved symptom severity. Evaluation of her AICD post-operatively yielded no abnormalities. Discussion: This case is an example of CVS with superimposed GP symptoms and demonstrates that treatment of GP can improve symptoms and restore quality of life. To our knowledge, this is the second reported case of successful GES implantation in a patient with an existing AICD. (PMID: 25031232). Certain precautions are recommended: continuous rhythm monitoring, inactivation of defibrillators during procedures using electrosurgical currents, and post-operative monitoring to ensure there is no crosstalk or artifact sensing. Interdisciplinary communication must occur to ensure complete device information and appropriate GES device selection. As the prevalence of implantable devices increases, careful consideration must be given to ensure safe and efficacious use of dual-IED therapy.