Journal of Geriatric Cardiology : JGC | 2021
Think twice before implanting leads in a swimmer: challenges in lead implantation of an implantable cardioverter-defibrillator
Abstract
A n 84-year-old male patient with an implantable cardioverter defibrillator (ICD) was admitted due to an alarming sound of his ICD. He had a left-sided, dual chamber, dual-coil ICD implanted 7 years ago due to ischemic cardiomyopathy and sick sinus disease. He was asymptomatic, with an excellent functional status. Of note, he was a highly active patient and a regular swimmer (6 months per year). His device interrogation revealed high-voltage lead impedance values over 3 000 Ohms, suggesting a lead fracture, which was confirmed by a chest X-ray (Figure 1A). Additionally, numerous sustained ventricular tachycardia episodes, properly treated, were identified. The decision for the implantation of a new ICD lead was made. This option was favored against the removal of the damaged lead, considering the high risks of such a procedure due to patient’s age and the long time-period since the initial lead implantation. During the procedure, the new lead could not be advanced because of left subclavian venous obstruction (Figure 1B). The decision to implant the new lead on the contralateral side was made. We performed a right subclavian venography, which unexpectedly revealed an additional subtotal obstruction of the vein, at the level near its join with the internal jugular vein (Figure 1C). The procedure was stopped and, in a second procedure, the obstruction in the right subclavian vein was treated with balloon angioplasty and stenting (Figure 1D), before successful re-implantation of the device from the left pocket to the right subclavian area, along with two new leads. The two left-sided leads were abandoned in place. The patient has remained asymptomatic during his two-year follow-up visits, with a good functional status, having followed instructions for limitation of strenuous exercise with the upper extremities. Moreover, chest X-rays have not shown evidence of damage in the venous stent struts after one and two years (Figure 2). We believe this to be an interesting case, because of the unusual asymptomatic finding of bilateral subclavian venous obstruction in this elderly patient. Ipsilateral asymptomatic subclavian venous obstruction after lead implantation for a cardiac implantable electronic device is not a rare phenomenon, making the implantation of a new lead challenging, in case of lead failure or a device upgrade. Patients carrying dual-coil ICDs carry an even higher risk for venous obstruction, due to increased lead diameter and the presence of a second coil in the superior vena cava. In cases of lead-associated venous occlusion, obscuring the implantation of a new lead, the presence of an additional venous stenosis on the contralateral side is not a frequent observation, and further complicates the clinical dilemmas. In our case, in the absence of traumaor tumor-related causes, one may be tempted to suspect the PagetSchroetter Syndrome, the venous variant of the thoracic outlet syndrome. It consists of axillary or subclavian vein thrombosis related to vein compression at the thoracic outlet, eventually with fibrosis and obstruction, attributed to regular and strenuous exercise, using the upper extremities. Anatomical anomalies of the thorax also predispose to this condition. Although the syndrome is encountered more commonly in much younger patients, our patient had been a very regular swimJournal of Geriatric Cardiology