Europace Advance Access originally published online on August 17, 2007
Europace 2007 9(12):1182-1183; doi:10.1093/europace/eum172
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CARDIAC RESYNCHRONISATION THERAPY
Late left ventricular lead displacement and treatment with a new endovenous active fixation lead
Department of Cardiology, Good Hope Hospital, Sutton Coldfield, West Midlands B75 7RR, UK
Manuscript submitted 29 May 2007. Accepted after revision 14 July 2007.
* Corresponding author. Tel: +44 7917718766. E-mail address: kayvan{at}nhs.net
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Left ventricular (LV) lead displacement is an early complication of biventricular pacemakers and leads to loss of capture, diaphragmatic pacing, and symptomatic deterioration, requiring a revision procedure. We report a case of late LV lead displacement following a coughing fit and treatment with a lead with a new principle of active fixation.
Key Words: Left ventricular lead displacement, Biventricular pacemakers
A 72-year-old female with NYHA III heart failure underwent biventricular pacemaker implantation. Using the left subclavian vein approach, an active right ventricular (RV) and right atrial (RA) lead was implanted. After exploring several tributaries with high thresholds, the LV lead (Medtronic 4193 and 4195, Medtronic Inc., Minneapolis, MN, USA) was implanted in an LV marginal branch. An initial early revision was required because of diaphragmatic pacing. Therefore, the middle cardiac vein was accessed and a threshold of 0.5 V at 0.5 ms was obtained. Two years later, during a coughing fit, the patient again developed diaphragmatic twitching. A chest radiograph confirmed LV lead displacement and deactivation of the device led to symptomatic deterioration. In a further revision, a Medtronic Starfix 4195 LV lead was implanted in a posterolateral vein obtaining an LV threshold of 0.5 V with a diaphragmatic pacing threshold of 4 V (Figure 1). Since re-implantation, her symptoms have once again improved.
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In contrast to the RA and RV leads, which can be fixed to the myocardium, the LV lead is positioned within a vein and relies on its bend shape for stability, making it more difficult to maintain its position on a long-term basis in some patients. Incidence of lead displacement is high in biventricular pacemakers, estimated at 5–9%. In a review of 400 patients, the incidence of LV lead displacement was 8.2%, comparable to other series.
There are no reports of lead displacement following coughing. Strategies to avoid or treat LV lead displacement include different shaped pacing leads and new leads with deployable wings. Because these leads can be removed, they may be preferable to stenting a conventional wire.
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