Author + information
- Received January 19, 2016
- Accepted January 29, 2016
- Published online March 23, 2016.
- David F. Briceno, MDa,
- Michael J. Grushko, MDa,
- Pedro A. Villablanca, MD, MSca,
- Florentino Lupercio, MDa,
- Andrew Krumerman, MDa,
- Kevin J. Ferrick, MDa,
- Soo G. Kim, MDa,
- John D. Fisher, MDa,
- Jay N. Gross, MDa,
- Linda B. Haramati, MD, MSb and
- Luigi Di Biase, MD, PhDa,c,d,e,∗ ()
- aMontefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
- bDepartment of Radiology and Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
- cTexas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas
- dDepartment of Biomedical Engineering, University of Texas, Austin, Texas
- eDepartment of Cardiology, University of Foggia, Foggia, Italy
- ↵∗Reprint requests and correspondence:
Dr. Luigi Di Biase, Arrhythmia Services, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, New York 10467.
A 64-year-old woman with Jervell and Lange-Nielsen syndrome and ventricular fibrillation being treated with nadolol was evaluated for shortness of breath. A dual-chamber implantable cardioverter-defibrillator (device model CD2207-36Q; ventricular lead model 7122Q/58; and atrial lead model 1688TC/52; all from St. Jude Medical, St. Paul, Minnesota) had been implanted in 2011 at an outside institution. Chest radiography revealed 2 lead fragments (Figure 1). The larger lead fragment was extra-cardiac, adjacent to the right heart border. This fragment was anterior to the heart, separated from the atrial lead. The smaller lead fragment was separate from and adjacent to the ventricular lead. Device interrogation demonstrated elevated atrial lead impedance and normal ventricular lead function. Fluoroscopy (Online Video 1) demonstrated that the large fragment lateral to the right atrial silhouette was static, confirming extra-cardiac lead migration. The smaller fragment moved along with the heart, suggesting a pericardial location. Computed tomography (CT) scan illustrated a distal fracture of the atrial lead (Figure 2), with the larger fragment implanted in the anterior pleural surface of the right middle lobe, adjacent to the anterior right fourth rib. The smaller lead fragment was in the anterior pericardial fat adjacent to the right ventricle. In view of the lack of pacing requirements and normal ventricular lead function, a multidisciplinary discussion was undertaken, and the ultimate decision was to continue a conservative approach. The patient remained asymptomatic in the outpatient setting.
This case illustrates an underrecognized course of an incidentally diagnosed lead fracture with migration into the lung and pericardium. It also highlights the diagnostic approach to lead fragment migration, including the use of fluoroscopy to discriminate anatomic locations and the importance of chest radiography to accurately assess lead complications (1). Spontaneous lead fragment fracture with migration is infrequent, and reports are scant (2,3); thus this case is important in terms of diagnosis and management.
Dr. Fisher is a consultant for Medtronic; and has received fellowship support from Medtronic, St. Jude Medical, Boston Scientific, and Biotronik. Dr. Di Biase is a consultant for Biosense Webster, Boston Scientific, and St. Jude Medical; and has received speaker honoraria and travel support from Medtronic, Atricure, EPiEP, and Biotronik. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 19, 2016.
- Accepted January 29, 2016.
- American College of Cardiology Foundation