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Review
. 2022 Oct 20;9(10):362.
doi: 10.3390/jcdd9100362.

Inadvertent Lead Malposition in the Left Heart during Implantation of Cardiac Electric Devices: A Systematic Review

Lorenzo Spighi  1 , Francesco Notaristefano  1 , Silvia Piraccini  1 , Giuseppe Giuffrè  1 , Alberto Barengo  1 , Matteo D'Ammando  1 , Salvatore Notaristefano  1 , Giuseppe Bagliani  1 , Gianluca Zingarini  1 , Fabio Angeli  2   3 , Paolo Verdecchia  1 , Claudio Cavallini  1
Affiliations
Review

Inadvertent Lead Malposition in the Left Heart during Implantation of Cardiac Electric Devices: A Systematic Review

Lorenzo Spighi et al. J Cardiovasc Dev Dis. .

Abstract

Background: The inadvertent lead malposition in the left heart (ILMLH) is an under-recognized event, which may complicate the implantation of cardiac electronic devices (CIEDs).

Methods: We investigated the clinical conditions associated with ILMLH and the treatment strategies in these patients. We made a systematic review of the literature and identified 132 studies which reported 157 patients with ILMLH.

Results: The mean age of patients was 68 years, and 83 were women. ILMLH was diagnosed, on average, 365 days after CIEDs implantation. Coexisting conditions were patent foramen ovale in 29% of patients, arterial puncture in 24%, perforation of the interatrial septum in 20%, atrial septal defect in 16% and perforation of the interventricular septum in 4%. At the time of diagnosis of ILMLH, 46% of patients were asymptomatic, 31% had acute TIA or stroke and 15% had overt heart failure. Overall, 14% of patients were receiving anticoagulants at the time of diagnosis of ILMLH. After diagnosis of ILMLH, percutaneous or surgical lead extraction was carried out in 93 patients (59%), whereas 43 (27%) received anticoagulation. During a mean 9-month follow-up after diagnosis of ILMLH, four patients experienced TIA or stroke (three on oral anticoagulant therapy and one after percutaneous lead extraction).

Conclusion: ILMLH is a rare complication, which is usually diagnosed about one year after implantation of CIEDs. An early diagnosis of ILMLH is important. Lead extraction is a safe and effective alternative to anticoagulants.

Keywords: anticoagulation; cardiac implantable electric devices; implantable cardioverter defibrillator; lead extraction; lead malposition; pacemaker; stroke; transient ischemic attack.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow diagram of the study.
Figure 2
Figure 2
Suggested diagnostic algorithm. A right bundle branch block morphology in V1 on the ECG despite Klein’s maneuver or an atypical position on the chest X-ray should prompt further investigations to rule out lead malposition.
Figure 3
Figure 3
Suggested treatment algorithm. Asymptomatic patients with very high surgical risk can be managed conservatively with vitamin K antagonists and INR between 2.5 and 3.5. For patients suitable for lead extraction, the surgical procedure can be preferred if the lead dwelling time is more than one year, the embolization risk is high, the lead is placed through the arterial route and if additional interventions must be performed (e.g., epicardial leads, congenital heart defect repair).
See this image and copyright information in PMC

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