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 As the lead was withdrawn, a covered stent was deployed at the entry site as described previously.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.
A 75-year-old caucasian male patient with a diagnosis of dilative cardiomyopathy (echocardiographic biplane ejection fraction (EF) 23%) had sinus rhythm with left LBBB ECG (Figure a-b) (QRS with 136 ms) and a profound dyssynergic contraction profile. There was a history of Diabetes Typ II, hypertension and mild renal insufficiency (serum creatinine 1.63 mg/dl). Significant coronary artery disease had been excluded by angiography. Currently, he suffered from New York Heart Association (NYHA) III heart failure status and was admitted for implantation of a CRT – implantable cardioverter defibrillator (ICD). The operative procedure was unremarkable, although some difficulties advancing the right electrode into the right ventricle were reported. Chest X-ray after implantation (Figure a-b) excluded pneumothorax and electrodes appeared well placed. The patient was discharged one day after the procedure when the pacing ECG showed a narrowed QRS complex (Figure c-d) with optimal values of all three electrodes (Table ).\nOne month later on follow-up, the patient reported a marked improvement of his exercise capacity (NYHA II). Electrode values remained stable. An unscheduled echocardiogramm (Philips iE33) revealed a marked reduction of left ventricular dimensions with an improved monoplane ejection fraction (51%). However, through the mitral valve leaflets a thick electrode proceeded into the apex of the left ventricle. An additional transesophageal echocardiographic examination demonstrated the coronary sinus (CS) electrode in place (Figure a) but a malposition of the RV electrode passing the patent foramen ovale (PFO) via an Eustachian valve into the left ventricle (3 b-d).\nAfter studying the literature and informing the patient about possible consequences a revision procedure was performed. The RV electrode was easily removed from the left ventricle but could not be safely placed in the right heart without a sheat. A new electrode was advanced and fixed at the base of the right ventricle. Postprocedure chest x-ray (Figure c-d), ECG (Figure e-f), and measurements (Table ) all documented good results. This time a postprocedure echocardiogramm showed an intact mitral valve, persistent good left performance, and the RV electrode within the right heart.\nThis was a clinical study and no experimental work. No ethical committee had to be involved. Everything happened in the compliance with the Helsinki Declaration.