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.