Introduction: To describe a novel method to deal with ICD lead fracture in very high risk patients with deep vein thrombosis
Methods: We describe the case of a 71-year-old man, with a CRT-D device (Biotronik Lumax 340 HF-T) implanted for 28 months, presenting with inappropriate ventricular arrhythmia detection on home monitoring report. The patient had a medical history of long lasting systemic arterial hypertension, insulin dependent diabetes mellitus, two coronary stents implanted for two years, severe peripheral arterial disease with no palpable limbs pulses, Acute Myocardial infarction at the age of 27 and femoral vein stent implanted for 2 months due to deep vein thrombosis. During this last hospitalization, left subclavian vein thrombosis was also found. The patient was in use of aspirin, clopidogrel and warfarin. Device interrogation showed 5 episodes of high frequency noise in the right ventricular sense/pace channel interpreted as ventricular tachycardia (VT) or Ventricular Fibrillation (VF). Two of these episodes led to capacitor charge, which was aborted prior to shock delivery. HV1 and HV2 channels showed no abnormalities. Echocardiogram showed severe left ventricular dysfunction and LVEF = 27%. Left ventricular lead sensing and impedance were normal. Due to the high complication risk, oral anticoagulant and dual antiplatelet therapy regimen, deep venous thrombosis and the advanced heart failure clinical status, we decided not to put another ICD lead on. The strategy planned was to do a less invasive procedure under local anesthesia. Procedure description: With the patient under local anesthesia the ICD pulse generator was exposed with minimum dissection. The Left and Right ventricular leads sense/pace channels were then switched in the pulse generator inlet and the generator was put back in place. Total procedure time was 30 minutes and the telemetry at the end showed good ventricular sensing at the right ventricular channel (left ventricular lead). The postoperative course was uneventful and the patient was discharged in postoperative day 1. Thirty three days after the procedure the patient had episodes of ventricular arrhythmia (VT and VF) promptly detected and treated by the device, returning to normal synus rhythm. The patient had no sequelae after this appropriate shock delivery.
Discussion: CRT-D patients tend to be high risk and with multiple comorbidities. Any medical intervention on them is accompanied by high morbidity/mortality risk. This patient had previous interventions indicating that deep venous access to put another ICD lead in would not be possible. There were no palpable peripheral pulses and an invasive arterial pressure line was not feasible, making general anesthesia a very high-risk approach. The surgical strategy adopted gave a secure path to fix the device problem. As long as the ventricular arrhythmia diagnosis are made by the right ventricular channel readings, the switch with the left ventricular lead provided a noise free tracing with safe diagnosis, that led ultimately to appropriate shock delivery in a life threatening episode.
Conclusions: This unique and novel approach was possible even in this very high-risk patient and turned into a life saving procedure as demonstrated by the subsequent arrhythmia episode. We think that all the ICD manufacturers should make it possible to make this ventricular channel switch during a outward electronic evaluation by device telemetry. If this change were made many patients with sensing/pacing right ventricular lead fractures would benefit from this.