Case 3
An 89-year-old male with a prior history of atrial fibrillation with tachy-brady syndrome s/p single chamber Medtronic pacemaker 9 months prior, status post left carotid endarterectomy, hypertension, hyperlipidemia, hypothyroidism, diabetes, COPD, GERD and BPH requiring home bladder catheterizations was referred for biventricular pacemaker upgrade for heart failure. After a challenging initial upgrade, the CS lead dislodged prompting referral for an endocardial LV lead placement. CS lead placement was again attempted however there were no favorable lateral branches. LV lead placement was then performed with the following variations:
Despite going through a PFO, at first pass the peel away sheath from above could not be fully advanced into the left atrium, as became clear when trying to advance the lead through the sheath. After several attempts to direct the lead to the LV, the apparatus was pulled back to the right side.  The transseptal was repeated, and this time, after the SL0 sheath was in the LA, the transseptal needle and dilator were exchanged for a deflectable quadripolar EP catheter. This allowed for greater maneuverability, and ultimately allowed the superior sheath to be directed to the LV. Additionally, there was a small, not hemodynamically significant pericardial effusion noted on TEE that remained stable throughout the procedure. On follow-up, the LV EF improved from 25-30% to 35-40% with further improvement to 40-45% 1 year post procedure with improvement to NYHA class II. On most recent follow-up 3 years post procedure there had been no complication from the LV endocardial lead including stroke or TIA, however, the patient expired from unrelated causes 4 years after the procedure.