Dual Rare Lead-Related Complications: A Case Report Highlighting Troubleshooting Challenges During ICD Lead Implantation.

BACKGROUND: LMNA-related dilated cardiomyopathy is associated with ventricular remodeling and a high arrhythmic risk, frequently requiring implantable cardioverter-defibrillator (ICD) implantation. Although transvenous systems are generally safe, rare lead-related complications may occur. CASE SUMMARY: We report a 51-year-old man with LMNA-related dilated cardiomyopathy who experienced 2 rare and sequential ICD lead complications. An initially septal right-ventricular lead was complicated by myocardial transfixion because of anterior apical positioning, revealed by cardiac computed tomography after a rise in pacing thresholds. During reintervention, a second lead was implanted but was later found to have traversed an unrecognized sinus venosus atrial septal defect with partial anomalous pulmonary venous return, resulting in inadvertent left-ventricular lead placement. The lead was successfully repositioned under transesophageal echocardiographic guidance. Three-dimensional computed tomography reconstruction clearly demonstrated both abnormal lead positions. DISCUSSION AND TAKE-HOME MESSAGE: This case highlights the importance of systematic troubleshooting, awareness of altered anatomy, and multimodality imaging during ICD implantation.