Unexpected posterior tilt in extravascular implantable cardioverter-defibrillator leads: Lessons learned from 3 cases

Figures

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  Figure 1. An example of flipping extravascular implantable cardioverter-defibrillator lead. A: Initial lead position immediately after introducer removal, with coils oriented to the right (arrows). B: The lead flipped 180 degrees within minutes, now with coils facing the left (arrows). The lead was removed and retunneled, aiming slightly more medially. C, D: Chest radiograph from the following day shows the final lead position near the sternum, with coils correctly oriented to the right. Note: These images are not associated with the reported cases.

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  Figure 2. Extravascular implantable cardioverter-defibrillator (EV-ICD) lead position in case 1. EV-ICD lead position during the implantation from the anteroposterior (A) and the left anterior oblique 90-degrees (B) views. Post-implantation chest radiograph shows unchangeable lead position in the anteroposterior view (C), but posterior tilting in the lateral view (D).

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  Figure 3. Postoperative computed tomography (CT) of case 1. The CT images (A, B) and 3-dimensional (3D) reconstruction (C, D) show posterior tilting of the extravascular implantable cardioverter-defibrillator lead toward the heart. The ribs were partly removed from the 3D reconstruction to visualize the position of the device. Image B shows the relatively narrow space between the inferior part of sternum and the cardiac structures can be seen. The retrosternal space is larger at the level of middle and superior one-third of the sternum. Images A and B show the streak-like, beam-hardening artifacts induced by the metallic pacing lead.

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  Figure 4. Postoperative chest radiograph of case 2. After an uneventful implantation, the extravascular implantable cardioverter-defibrillator lead demonstrates a tilt toward the heart.

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  Figure 5. Extravascular implantable cardioverter-defibrillator lead position change in case 3. After the initial substernal position, the lead has tilted posteriorly and shifted slightly to the right during the 2 days to follow-up.