Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: A multicenter experience and review of the literature

Three patients from different centers with pacemaker or ICD leads endocardi ally implanted in the left ventricle are described. All leads, two ventricu lar pacing leads and one ICD lead, were inserted through a patent foramen o vale or an atrial septum defect. The diagnosis was made 9 months, 14 months , and 16 years, respectively, after implantation. All patients had right bu ndle branch block configuration during ventricular pacing. Chest X ray was suggestive of a left-sided positioned lead except in the ICD patient. Diagn osis was confirmed with echocardiography in all patients. One patient with a ventricular pacing lead presented with a transient ischemic attack at I-m onth postimplantation. During surgical repair of the atrial septum defect 1 4 months later, the lead was extracted and thrombus was attached to the lea d despite therapy with aspirin. The other patients were asymptomatic withou t anticoagulation (9 months and 16 years after implant). No thrombus was pr esent on the ICD lead at the time of the cardiac transplantation in one pat ient. We reviewed 27 patients with permanent leads described in the literat ure. Ten patients experienced thromboembolic complications, including three of ten patients on antiplatelet therapy. The lead was removed in six patie nts, anticoclgulation with warfarin was effective for secondary prevention in the four remaining patients. In the asymptomatic patients, the lead was removed in five patients. in the remaining patients, 1 patient was on warfa rin, 2 were on antiplatelet therapy and in 3 patients the medication was un known. After malposition was diagnosed, three additional patients were trea ted with warfarin. In conclusion, if timely removal of a malpositioned lead in the left ventricle is not preformed, lifelong anticoagulation with warf arin can be recommended as the first choice therapy and lead extraction res erved in case of failure or during concomitant surgery.