We report the case of a 65-year-old man affected by dilated cardiomyopathy associated with severe mitral valve regurgitation, recently treated by 2 MitraClip System devices (Abbott Vascular, Lake Bluff, IL) implantation. Three months after valve repair, the patient underwent to dual-chamber defibrillator implantation because the persistence of seriously dilatation and marked systolic impairment of the LV (ejection fraction = 30%) with mild mitral valve regurgitation. The patient performed a predischarge electronic check of the device that showed its normal function. He came to our observation, 2 months later, for marked deterioration of the dyspnea, despite his strict compliance to medical therapy. At this time, the 2-dimensional (2D) echocardiographic examination showed malposition of the shock lead that appeared placed in the apex of the LV through an iatrogenic atrial septal defect (ASD) persisted after the percutaneous valve repairing procedure, previously performed (Fig. A); the LV appeared markedly dilated and presented a severe systolic dysfunction (ejection fraction = 30%). The echocardiographic color-Doppler view showed a moderate mitral valve regurgitation and a significant mitral valve stenosis attested by an accelerated transvalvular diastolic flow (Fig. B). The transesophageal 3-dimensional-echocardiographic short axis view on mitral annulus showed a normal implantation of the MitraClip devices on the edges of mitral valve leaflets and a noncontinuity solution between MitraClip devices and the defibrillator lead (Fig. ). The 12-lead standard electrocardiogram (ECG) showed normal sinus rhythm to 67 bpm and its record during the pacing threshold test bared a right bundle branch block (RBBB) pattern of the QRS complex (Fig. A). Chest X-ray documented a very lateral position of the defibrillator lead (Fig. A). Oral anticoagulation therapy with adjusted-dose warfarin was directly started and, after obtaining the patient's informed consent, a mechanical lead extraction with subsequently lead repositioning in the right ventricle (RV) was performed 3 weeks later. The patient was discharged in good clinical condition and the 12-lead ECG and the chest X-ray, performed in the predischarge phase, confirmed the right position of the defibrillator lead, respectively, showing a left and superior direction of the QRS complex axis, during ventricular pacing (Fig. B) and a conventional position of the lead in the apex of the RV (Fig. B). The predischarge echocardiographic examination showed left ventricular systolic dysfunction (ejection fraction 34%) with mild mitral valve regurgitation and a not relevant velocity of trans-mitral diastolic flow. The follow-up performed 1 month after discharge was uneventful. Ethical approval for this paper was not required by the Ethics Committee of our institute, as it is a case report. The patient provided informed consent for this report and his medical data have been anonymized.
A 23-year-old female with Ebstein's anomaly of tricuspid valve underwent one and half ventricular repair with tricuspid valve annuloplasty, atrial septal defect closure and cavopulmonary anastamosis of right superior venacava to the right pulmonary artery. She also needed dual chamber pacing for symptomatic bradycardia secondary to sinus nodal and atrioventricular nodal disease. There was no pre-excitation or tachyarrhythmias. Left atrial and left ventricular epicardial leads were connected to a pulse generator that was implanted in epigastric subcutaneous pocket. There was synchronous atrioventricular pacing with acceptable pacing thresholds during the time of implantation. Three months later, new onset symptomatic diaphragmatic pacing was observed from atrial lead. So the pacemaker was reprogrammed to pace ventricle alone. After another two months, diaphragmatic pacing was observed from ventricular lead too. The threshold voltage for ventricular capture was more than that of the diaphragm. The reasons for delayed onset diaphragmatic pacing through both leads almost five months after the epicardial lead placement and pacemaker implantation was not understood. Her symptoms related to bradycardia warranted permanent dual chamber pacing. Since extensive dissections will be needed through the previous surgical scars and adhesions in midline sternotomy and left thoracotomy, a second epicardial lead repositioning was not considered. A minimal incision right anterolateral thoracotomy was made and two introducer sheaths were inserted through two pursestring sutures placed on the right atrial free wall.() Two screw-in endocardial leads were inserted through the sheaths under transesophageal echocardiographic guidance into the right atrial appendage tip and right ventricular apex to achieve atrioventricular pacing. On a follow up of nine months, the patient was asymptomatic, pacing was synchronous and chest X-ray showed both the new and old leads. ()