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 As the lead was withdrawn, a covered stent was deployed at the entry site as described previously.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 64-year-old female, with multiple previous hospitalizations for acute heart failure, was admitted for shortness of breath, peripheral edema, and increasing abdominal size in her local hospital emergency department with subsequent hospitalization. She had a history of idiopathic dilated cardiomyopathy with severe biventricular systolic dysfunction, secondary severe mitral and tricuspid regurgitation, and permanent atrial fibrillation. As part of the sequence of heart failure therapies, the patient also had a previous implant of an ICD for primary prevention 5 years before.\nDuring hospitalization, the patient developed diverse infectious complications which contributed to a slow resolution of acute heart failure, with the need of many days of inotropic and vasopressor support and subsequent suboptimization of heart failure therapy. As the patient was recognized as having criteria for advanced heart failure, she was referred and transferred to our advanced heart failure center.\nFollowing admission to our hospital, an ECG was performed, showing ventricular paced rhythm with RBBB pattern in V1 through V5 leads and extreme right axis displacement of the mean QRS in the frontal plane clearly indicating an electrical activation from the left ventricle [], which raised suspicion of ICD lead malposition. Chest radiography was performed also showing an abnormal lead path, suggestive of implantation of the lead in the left ventricle []. To confirm our suspicion, our patient then performed a transthoracic echocardiogram, which showed biventricular dilatation with moderate systolic dysfunction, severe mitral and tricuspid regurgitation, and signs of right ventricular pressure overload with plethoric inferior vena cava and abnormal septal motion with systolic “flattening” toward the left ventricle. Peak systolic gradient between the right ventricle and the right atrium was normal, probably underestimated because of right ventricular dysfunction and severe enlargement of the right atrium. However, the implanted ICD appeared to pass through the interatrial septum, with its lead tip in contact with the midsegment of the left ventricular anterolateral wall [-]. Our patient also underwent a transesophageal echocardiogram to better clarify valvular regurgitations and the behavior of the ICD lead at the level of the interatrial septum [-].\nInitially, our patient registered an important decrease in body weight and improvement in symptoms; however, after many days of stay, her hospitalization was complicated with refractory ascites and cardiogenic shock, with fast progression in INTERMACS classification. As our patient reached INTERMACS Level 2, we launched a desperate appeal for cardiac transplantation, as neither extracorporeal membrane oxygenation nor left ventricular assist devices were available at our center at the time. After a couple of days, we got contacted as there was an available heart, and our patient was promptly transferred to our cardiac surgery unit where she underwent successful orthotopic heart transplantation. Analysis of the explanted heart confirmed the presence in the left ventricle of the ICD catheter. Immediate postoperative course was favorable with extubation after 24 h, requiring inotropic support with dobutamine for 2 days with no need for mechanical support. The patient was discharged after 72 days after transplantation, and to this day remains symptom-free with no further hospitalizations.