Case presentation
A 76-year-old man with history of ischemic cardiomyopathy and paroxysmal atrial fibrillation who underwent a Dual-Chamber Medtronic Implantable Cardioverter-Defibrillator (ICD) placement 6 years earlier in an outside facility presented to the emergency room with worsening shortness of breath. Initial workup in the emergency room revealed acute on chronic combined congestive heart failure. An AP chest X-ray film showed cardiomegaly with pulmonary vascular congestion and satisfactory ICD lead position (Figure 2 ). No lateral view was obtained at the time.
Bedside Echo showed severely reduced left ventricular systolic function with dilated right ventricle and moderate to severe pulmonary hypertension. Surprisingly, the ICD lead was clearly going from the left atrium through the mitral valve to the left ventricular cavity (Figure 3, 4 and 5 ). A lateral chest x-ray view revealed that the ICD shock lead tip is directed posteriorly, indicating its presence in the left ventricular cavity (Figure 6 ). A transesophageal echocardiogram showed the ICD lead went from the superior vena cava to the right atrium, crossing through a small sinus venous atrial septal defect to the left atrium, and into the left ventricular cavity via the mitral valve. Luckily, the patient was on chronic anticoagulant because of chronic atrial fibrillation, so no thromboembolic complications were reported. Interestingly enough, the patient had 2 prior trans-thoracic echocardiograms that were interpreted by the same cardiologist without mention of abnormal ICD lead placement.
Because extraction of a chronically implanted ICD lead carries a high risk of major cardiovascular complications (2 to 4%) including vascular injury, cardiac perforation resulting in cardiac tamponade, and occasionally thromboembolic complications or even death, and because the patient was chronically anticoagulated, the decision is made to continue conservative management.