ICD Lead Migration: A Lesson to Learn

Implantable Cardioverter Defibrillator (ICD) was initially used for secondary prevention of sudden cardiac death due to VF/ VT [1]. The first use of ICD to prevent sudden cardiac death was in 1980 [1]. Currently, ICD is indicated for secondary prevention of SCD due to sustained VT or VF (in whom there is no identifiable cause) and primary prevention of SCD in patients who are at risks of SCD due to VT/VF2. This includes patients with ischemic cardiomyopathy with EF ≤ 30% or non-ischemic cardiomyopathy with NYHA class II/III and EF ≤ 35%. ICD is not recommended if the patient survival is less than a year or if there are reversible causes [2]. More often, patients who are candidates for ICD are also candidate for Cardiac Resynchronization Therapy RCT (or biventricular pacing) if QRS duration ≥ 120 milliseconds [3]. Compared to medical therapy, CRT improves survival according to CARE-HF trial [4]. Combination of both biventricular pacing and ICD is recommended to reduce mortality and morbidity in patients with heart failure and prolonged QRS complex [3]. According to COMPANION trial, the benefit of this combination is greatest in presence of LBBB and QRS ≥ 150 milliseconds [5]. ICD insertion carries a risk of major complications like cardiac perforation, bleeding and infection. The overall rate of ICD lead insertion complication is around 3-6 percent [6,7]. One large cohort study has shown 5.4% incidence of major complications requiring reoperation or hospitalisation in the first 90 days after the procedure [8]. Cardiac perforation incidence is 0.14% and usually associated with significant mortality and morbidity [9]. In this case report, ICD lead migration with unusual presentation is discussed. The case was referred to our cardiothoracic unit at Blackpool Teaching Hospital for ICD lead extraction