A 76-year-old man with history of ischemic cardiomyopathy and paroxysmal atrial fibrillation who underwent a Dual-Chamber Medtronic Implantable Cardioverter-Defibrillator (ICD) placement 6 years earlier in an outside facility presented to the emergency room with worsening shortness of breath. Initial workup in the emergency room revealed acute on chronic combined congestive heart failure. An AP chest X-ray film was interpreted by the radiologist as cardiomegaly with pulmonary vascular congestion and satisfactory ICD lead position (Figure ). No lateral view was obtained at the time.\nBedside Echo showed severely reduced left ventricular systolic function with dilated right ventricle and moderate-to-severe pulmonary hypertension. Surprisingly, the ICD lead was clearly going from the left atrium through the mitral valve to the left ventricular cavity (Figures , , and ). A lateral chest X-ray view revealed that the ICD shock lead tip is directed posteriorly, indicating its presence in the left ventricular cavity (Figure ). A transesophageal echocardiogram showed the ICD lead went from the superior vena cava to the right atrium, crossing through a small sinus venous atrial septal defect to the left atrium, and into the left ventricular cavity via the mitral valve. Luckily, the patient was on chronic anticoagulant because of chronic atrial fibrillation, so no thromboembolic complications were reported. Interestingly enough, the patient had two prior trans-thoracic echocardiograms that were interpreted by the same cardiologist without mention of abnormal ICD lead placement. Furthermore, prior ICD interrogation reports from his primary cardiologist showed chronically elevated shock lead impedance but pacing threshold and sensing were good. No therapy was needed since device implantation.\nBecause extraction of a chronically implanted ICD lead carries a high risk of major cardiovascular complications (2%-4%) including vascular injury, cardiac perforation resulting in cardiac tamponade, and occasionally thromboembolic complications or even death, and because the patient was chronically anticoagulated, the decision is made to continue conservative management.
A 63 year old male with history of ischemic cardiomyopathy and single chamber ICD with a dual coil active fixation lead implanted twelve months prior to presentation, underwent routine echocardiography identifying the lead localized in the aortic root and crossing the aortic valve. The proximal coil was adjacent to the right coronary cusp. The patient had recurrent gastrointestinal bleeding prohibiting long term anticoagulation therapy. Considering the thromboembolic risk of arterial lead placement and concern for adhesion near the ostium of the right coronary artery, we opted to proceed with transarterial lead extraction. Under general anesthesia and in the hybrid operating room, the subpectoral pocket was exposed. Thoracic aortic arch and carotid angiography was performed, and distal embolic filter wires were deployed in the right and left internal carotid arteries following anticoagulation with unfractionated heparin. Intravascular ultrasound of the left subclavian artery was performed to localize the lead entry point at the left subclavian artery and determine appropriate reference vessel sizing for stent graft placement. As the lead was withdrawn, a covered stent was deployed at the entry site as described previously. There were no neurological or vascular complications following the procedure. Reimplantation of a cardiac resynchronization device was performed electively via the left subclavian vein without any complications.