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.
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.