B-po03-056 culprit, bystander, or a hole other matter: endocardial lv pacemaker lead extraction for severe mitral regurgitation

LV endocardial lead placement for CRT can be performed, usually when conventional means of CRT have been exhausted. LV endocardial lead placement may have unintended consequences on the mitral valve leading to incomplete coaptation and mitral regurgitation. The indications for extraction of an LV endocardial lead for mitral valve disease and potential long-term consequences are less clear. To understand potential consequences of LV lead placement and extraction. N/A We present a 78-year-old female with a dual chamber pacemaker for intermittent complete heart block who developed progressive decline in LVEF in the setting of high RV pacing burden. Placement of a coronary sinus lead was unsuccessful following two attempts and epicardial lead placement was deferred due to patient preference. An LV endocardial lead was placed via atrial trans-septal access. There was mild mitral regurgitation at the time of implant. Five years later she developed clinical heart failure with severe mitral regurgitation and suspected P3 scallop impingement. The LV endocardial lead was extracted using a laser sheath through the interatrial septum. A HIS bundle pacing lead was placed. The intraoperative TEE did not demonstrate improvement in mitral regurgitation. She had subsequent heart failure admissions and repeat TEE was performed demonstrating moderate to severe mitral regurgitation with incomplete A1/P1 coaptation. She was not felt to be a candidate for percutaneous repair of her valve. She was also found to have a persistent 1.1cm atrial septal defect with bidirectional shunt following device extraction. RHC demonstrated a Qp/Qs of 2.36. She is now referred for atrial septal defect closure. This case highlights the uncertainty in identifying LV endocardial leads as the cause of clinically significant mitral regurgitation. Our patient's mitral regurgitation did not recover appreciably following lead extraction suggesting that functional valve disease played a more significant role. The unclear benefit of lead extraction should be carefully weighed against its risk which includes worsening mitral regurgitation and residual atrial septal defect.