23. Left Ventricular Quadripolar Lead in Phrenic Nerve Stimulation

In 2010 the patient reported dyspnea with New York Heart Association (NYHA) class II, then class III. A nonischemic dilated cardiomyopathy was diagnosed. The surface electrocardiogram (ECG) showed a complete left bundle branch block (LBBB) and the echocardiography a left ventricular ejection fraction (LVEF) of 25% and a left ventricular end-diastolic diameter of 63 mm. A medical treatment including angiotensin-converting enzyme inhibitors, beta blockers, and diuretics was prescribed with a significant improvement in symptoms and echocardiographic parameters over 1 year. A NYHA class II to III dyspnea occurred in 2012, as well as a deterioration in LVEF (25%). The implantation of a cardiac resynchronization therapy defibrillator (CRT-D) was attempted in another center, but the left ventricular lead could not be implanted because of a coronary sinus dissection. A CRT-D device was implanted, with a plug into the left ventricular port. The patient was referred to our center 2 months later for a new attempt of left ventricular lead implantation. Computed tomography (CT) was performed to assess the patency of the coronary sinus. A Medtronic 4194 (Minneapolis, Minn.) left ventricular lead was implanted into a lateral vein. The lead must be positioned at the proximal part of the lateral vein because of a permanent phrenic nerve simulation at the distal and medial part of the vein despite the electrical repositioning. The following day the chest radiograph showed the dislodgement of the left ventricle lead into the body of the coronary sinus.

The patient was taking bisoprolol 10 mg daily, ramipril 10 mg daily, eplerenone 50 mg daily, and furosemide 40 mg daily.

The patient was experiencing dyspnea with NYHA class III and no signs of right heart failure.