Laser-based lead extraction of an accidentally left ventricular placed ICD lead

Introduction: Accidentally left ventricular (LV) placed pacemaker or ICD leads are rarely events.

Recently, we successfully extracted an accidentally left ventricular placed ICD lead by use of an excimer laser device.

Case report: 68-year-old woman with history of dilated cardiomyopathy, an ejection fraction of 40%, episodes of syncope, ventricular fibrillation and cardio pulmonary reanimation received a single chamber ICD in May 2000 for secondary prophylaxis.

Following ”uncomplicated” implantation a generator exchange was performed in September 2005. In October 2012, an impairment of ventricular sensing was noted during a routine ICD follow-up examination and therefore lead revision scheduled. In order to pre-operatively rule out lead vegetations a transesophageal echocardiography (TEE) was conducted. Surprisingly, the single coil ICD screw-in lead was located in left ventricular malposition. Immediately, warfarin was decreed to prevent thrombotic embolism. Subsequently patient was admitted to our hospital in order to extract the malpositioned ICD lead and to implant a new lead into the right ventricle. The procedure was performed under general anaesthesia, TEE control and stad-by extracorporeal circulation (ECC) unit. First we intended to extract the lead by moderate mechanical traction. This approach was due to massive adhesions in subclavian vein, superior cava vein and in the passage through atrial septum not successful. In TEE a marginal left-right shunt next to the lead while passing the atrial septum, as well as mitral regurgitation grade I were diagnosed. We decided to extract the lead via excimer laser. First, a new right ventricular screw-in ICD lead was placed. Afterwards, an EZ lead-locking device was introduced and 14 Fr. laser sheath instead of usually used 16 Fr. was used in order prevent arterial air embolism and to minimize risk of widening atrial PFO. After mobilization of massive adhesions in left subclavian vein and superior vena cava, and relatively easy passage through atrial septum and mitral valve we struggled to release the adhesions in LV. After complete lead removal no signs of mitral valve regurgitation increase and only small left-right shunt in atrial septum was documented. There were no complications observed in the postoperative course.

Conclusion: Excimer laser-based extraction of an accidentally LV placed ICD lead is possible. Two-plane X-ray control after ICD implantation may prevent lead malposition in the LV.