Case 1
A 71 year-old female patient with a past medical history of
hypertension, dyslipidemia, breast cancer in remission after left
radical mastectomy, chemotherapy and radiation therapy in the late
1990’s, paroxysmal atrial fibrillation on warfarin therapy, symptomatic
complete heart block with a dual chamber pacemaker 7 years prior to the
procedure, non-ischemic cardiomyopathy and previously preserved ejection
fraction (EF) was referred for upgrade to a Bi-V ICD after a decline in
her EF to 20% and progression of HF symptoms. Unfortunately, attempts
at CS lead placement were unsuccessful and the pacemaker was only
upgraded to a dual chamber ICD. She continued to have heart failure
symptoms and an attempt was made to upgrade her to a Bi-V ICD. During
the procedure she was noted to have an occluded axillary vein and
underwent extraction of a previously abandoned RV lead. Following
extraction, another attempt to place a CS lead was unsuccessful due to a
lack of target branches. An LV endocardial lead was placed using the
procedure described above. The procedure was well tolerated, and
warfarin was resumed with a heparin bridge, targeting an INR of 2.5-3.5.
Her EF did not improve after 3 years of follow-up. On follow-up of 6
years there has been no evidence of TIA or stroke, but she had developed
severe mitral regurgitation from lead impingement on the mitral valve.
She developed worsened heart failure symptoms, prompting plan for LV
lead extraction with plan for attempt at physiologic pacing.