Case History/Presentation
A 79-year-old man with a CRT defibrillator (CRTD) was hospitalised due
to a New York Heart Association (NYHA) functional class 3 HF as a result
of LV lead fracture and CRT breakdown.
He was previously diagnosed with dilated cardiomyopathy and
long-standing atrial fibrillation (AF). In 2012, a CRTD was implanted
for the NYHA functional class 2 HF that developed due to bradycardia
during AF, progressive LV remodelling showing an LVEF of 29%, and
accompanying non-sustained ventricular tachycardia. CRTD (Viva XT
CRT-D™; Medtronic Inc., Minneapolis, MN, USA) implantation was performed
using a transvenous approach. A right ventricular (RV) defibrillation
lead (Sprint Quattro™; Medtronic Inc.) was implanted using the left
cephalic vein cutdown approach. Atrial (CapSure Fix NOVUS™; Medtronic
Inc.) and LV (Attain Star Fix™; Medtronic Inc.) leads were implanted via
a left subclavian veinous puncture. However, there was almost no
suitable placement site for the LV lead due to diaphragmatic twitching
and poor pacing threshold issues along with the left marginal and middle
cardiac veins. Since the distal end of middle cardiac vein and the
ostium site of left marginal vein were barely acceptable for LV lead
placement, LV lead was implanted deeply into middle cardiac vein to
place the LV lead tip at the apical region of the LV lateral wall where
no diaphragmatic twitching was found despite poor pacing threshold of
3.5 V at 1.0 ms at least during the operation (Figure 1a, b).
Unfortunately, reoperation was necessary after 7 days, because the LV
lead threshold increased to 5.5 V at 0.4 ms, with the LV ring to RV coil
configuration, and diaphragmatic twitching occurred at 1.0 V at 0.4 ms,
with the LV tip to LV ring or RV coil configuration. The LV lead was
relocated to the basal region of the LV anterolateral wall through the
left marginal vein (Figure 1c). Fortunately, CRT could be continued
after reoperation, contributing to an improvement in the HF symptoms
from the NYHA functional class 2 to class 1 despite a wider paced QRS
duration of 166 ms.
Rehospitalisation due to HF was not required for 7 years following the
CRTD implantation while reprogramming to the ventricular-ventricular
inhibited pacing mode due to the progression to permanent AF and atrial
lead fracture at 2 years after the CRTD implantation in 2014.
In 2019, at 7 years after the CRTD implantation, the patient required
rehospitalisation for HF twice, and over the course of the year, his HF
symptoms had gradually progressed from the NYHA functional class 1 to
class 2 following a decrease in the LVEF to 26% and widening of the
paced QRS at around 190 ms.
In 2020, at 8 years after the CRTD implantation, the patient was
rehospitalised for acute decompensated HF due to LV lead fracture and
CRT breakdown. The chest radiograph showed complete fracture of the LV
lead and pulmonary congestion (Figure 2a). A 12-lead electrocardiogram
showed RV pacing with a wider QRS duration of 234 ms (Figure 2b). An
emergent interrogation of the CRTD revealed an LV lead impedance of over
3000 Ω, resulting in the LV pacing failure, even during maximum pacing
amplitude and duration. The echocardiographic evaluation showed
dyssynchronous LV motion and decrease in the LVEF to 20% under RV
pacing. Worsening HF was diagnosed as being caused by the RV pacing
because of complete LV lead fracture and CRT breakdown. The
decompensated HF improved only during intravenous furosemide
administration under in-hospital conditions. After HF compensation,
troubleshooting to LV lead fracture was discussed by our cardiovascular
team, including cardiovascular surgeons. As a result, we decided to
implant the epicardial LV lead via lateral thoracotomy considering that
the acceptable LV pacing site transvenously was exclusively confined to
the basal region of the LV anterolateral wall through the left marginal
vein and can progress myocardial damage according to the history of
recent HF development and widening of paced QRS. On day 13, an
epicardial bipolar LV lead (CapSure Epi™, Medtronic Inc.) was sutured at
the LV posterolateral wall of visually vital myocardium. The CRTD was
also replaced with the same model during the procedure (Figure 3a, b). A
post-operative 12-lead electrocardiogram showed biventricular pacing
with a narrower paced QRS duration of 178 ms (Fig. 3c). On day 27, the
patient was discharged uneventfully without any serious surgical
complications. At the 6-month follow-up, his HF symptoms had reverted to
the former NYHA functional class 2 level, with no recurrence of HF or
need for readmission.