Provocative Cases -> Teaching Case Reports D-PO01 - Featured Poster Session (ID 11) Poster

D-PO01-106 - Unleashing A Storm: An Unintended Consequence Of Lead-extraction (ID 95)

Abstract

Background: Lead extraction carries known procedural risk, though association with post-procedural arrhythmia is unclear.
Objective: We report a case of ventricular ectopy from a prior lead implant site with new onset, premature ventricular complex (PVC)-initiated polymorphic ventricular tachycardia (PMVT) storm following lead extraction.
Results: A 39 year old woman with a dual chamber pacemaker for complete heart block and pacemaker-dependence was referred for laser lead extraction due to RV lead fracture and subclavian vein occlusion. Extraction was difficult due to extensive binding at the lead tip in the low RVOT, but was ultimately successful. Immediately following lead removal, frequent, monomorphic PVCs initiating PMVT were observed. PMVT occurred again hours after her procedure. Morphology of the initiating PVC was a match to prior paced QRS morphology (Figure). With beta blockers, flecainide, and higher programmed lower rate no further ectopy was observed and she was discharged with a wearable defibrillator. Unfortunately, 6 weeks later she experienced syncope. Interrogation revealed 78 seconds of PMVT with device EGM match of the initiating PVC to prior events. Without PVCs to map at baseline, catheter ablation was performed at the site of prior lead implant using 3D merge of her pre-extraction CT and pace-mapping to device EGM for guidance. She subsequently underwent ICD upgrade and has had no further ventricular arrhythmias over limited follow up.
Conclusion: Malignant ventricular arrhythmia triggered from lead extraction is a previously unreported procedural risk. Further study is needed to understand the natural history of this complication.
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