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Three patients from different centers with pacemaker or ICD leads endocardially implanted in the left ventricle are described. All leads, two ventricular pacing leads and one ICD lead, were inserted through a patent foramen ovale or an atrial septum defect. The diagnosis was made 9 months, 14 months, and 16 years, respectively, after implantation. All patients had right bundle branch block configuration during ventricular pacing. Chest X ray was suggestive of a left-sided positioned lead except in the ICD patient. Diagnosis was confirmed with echocardiography in all patients. One patient with a ventricular pacing lead presented with a transient ischemic attack at 1-month postimplantation. During surgical repair of the atrial septum defect 14 months later, the lead was extracted and thrombus was attached to the lead despite therapy with aspirin. The other patients were asymptomatic without anticoagulation (9 months and 16 years after implant). No thrombus was present on the ICD lead at the time of the cardiac transplantation in one patient. We reviewed 27 patients with permanent leads described in the literature. Ten patients experienced thromboembolic complications, including three of ten patients on antiplatelet therapy. The lead was removed in six patients, anticoagulation 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 warfarin, 2 were on antiplatelet therapy, and in 3 patients the medication was unknown. After malposition was diagnosed, three additional patients were treated with warfarin. In conclusion, if timely removal of a malpositioned lead in the left ventricle is not preformed, lifelong anticoagulation with warfarin can be recommended as the first choice therapy and lead extraction reserved in case of failure or during concomitant surgery.

The LVdP/dt(max) is higher in LV than in BiV pacing provided that LV pacing is associated with ventricular fusion caused by intrinsic activation.

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AimsThe maximum rate of left ventricular (LV) pressure rise (dP/dt max ) has been used to assess the acute haemodynamic effect of cardiac resynchronization therapy (CRT). We tested the hypothesis that LV dP/dt max predicts long-term clinical outcome after initiation of CRT. Methods and resultsThis was a retrospective observational multicentre study in 285 patients in whom dP/dt max was measured invasively following implantation of a CRT device. The minimum required follow-up was 1 year. We analysed the relationship between dP/dt max and time to the composite endpoint, consisting of all-cause mortality, heart transplantation (HTX), or LV assist device (LVAD) implantation within the first year of CRT. Thirty-four events occurred after a mean followup of 160 days (range 21 -359). Patients with an event had lower dP/dt max than patients without an event both at baseline (705 + 194 vs. 800 + 222 mmHg/s, P ¼ 0.018) and during CRT (894 + 224 vs. 985 + 244 mmHg/s, P ¼ 0.033), but the acute increase in dP/dt max was similar in patients with and without an event (190 + 133 vs. 185 + 115 mmHg/s, P ¼ n.s.). Left ventricular dP/dt max -level at baseline and during CRT both predicted the clinical outcome after adjustment for gender, aetiology and New York Heart Association class: hazard ratio (HR) 0.791 [95% confidence interval (CI) 0.658-0.950, P ¼ 0.012] and HR 0.846 (95% CI 0.723-0.991, P ¼ 0.038), respectively. ConclusionLeft ventricular dP/dt max measured at baseline and during CRT are predictors of 1-year survival free from all-cause mortality, HTX, or LVAD implantation, but the acute improvement in dP/dt max is not correlated to clinical outcome.--

Needle's Eye Snare lead extraction has a low complication rate. The technique should be considered as a primary tool for extraction of pacing leads, particularly atrial and coronary sinus pacing leads. The results for extracting ventricular leads might be improved if larger bore sheaths with a better cutting edge were available.