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.