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Europace Advance Access originally published online on February 21, 2008
Europace 2008 10(4):458; doi:10.1093/europace/eun034
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org

ICD FOR PRIMARY PREVENTION: MORE IMPLANTS ARE NEEDED

Coronary artery fistula caused by an endocardial active fixation ICD lead

Tobias Härle*, Jacobus Reimers and Anselm Schaumann

Department of Cardiology, Asklepios Klinik St Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany

Manuscript submitted 2 January 2008. Accepted after revision 21 January 2008.

* Corresponding author. Tel: +49 40 181885 2305; fax: +49 40 181885 4444. E-mail address: t.haerle{at}gmx.de

Key Words: Coronary artery fistula, Shunt, ICD lead

A 63-year-old man with a history of chronic heart failure due to non-ischaemic cardiomyopathy presented with dyspnoea, peripheral oedema, chest pain, and a new systolic heart murmur. A pacemaker had been implanted 18 years ago because of a symptomatic sick sinus syndrome. Surgical mitral valve reconstruction was done 3 years ago for progressive mitral regurgitation. At that time coronary angiography had shown no pathological findings.

One year later, a biventricular implantable cardioverter-defibrillator (ICD) had been implanted for primary prevention of sudden cardiac death and device therapy in heart failure because of reduced left ventricular function (ejection fraction 0.26%) and left bundle branch block with dyssynchrony.

Coronary angiography during the current admission revealed a large coronary artery fistula from the left anterior descending artery to the right ventricle (Figure 1). The fistula was adjacent to the tip of the screw-in endocardial ICD lead, which penetrated into a small septal vessel. Therefore, formation of the coronary artery fistula has to be stated as a complication of the ICD lead placement.


Figure 1
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  		Figure 1 Coronary artery fistula originating from a septal branch of the left anterior descending artery and draining into the right ventricle secondary to implantation of a screw-in endocardial ICD lead. (A) Left lateral view. (B) Left anterior oblique view.

 
In order to quantify the shunt, right-heart catheterization with an oximetry run was performed, revealing a small left-to-right shunt of 0.29 L/min (8%; QP/QS = 1.1). Pulmonary artery and right-heart pressures were within the normal range. There were no signs of perforation, and pericardial effusion was excluded. A check of the ICD demonstrated appropriate function with stable values for sensing, pacing threshold, and impedance.

Due to the small shunt volume, a conservative therapy approach was chosen, and symptoms of heart failure were regressive under optimized medical therapy.


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This Article
Right arrow FREE Full Text (PDF) Freely available
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Right arrow All Versions of this Article:
10/4/458    most recent
eun034v1
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Right arrow Articles by Härle, T.
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