Guide Wire Fracture During Cardiac Resynchronization Therapy Implantation and Subsequent Management

History

A 65-year-old man with ischemic dilated cardiomyopathy, already treated by stenting of the anterior interventricular coronary artery and then by coronary artery bypass graft surgery, received a dual-chamber implantable cardioverter-defibrillator (ICD) 4 years previously for primary prevention of sudden cardiac death. At that moment the electrocardiogram (ECG) showed an incomplete left bundle branch block (LBBB) with a QRS duration of less than 120 ms. The patient was later admitted to the hospital because of acute heart failure decompensation. During the last 6 months his functional capacity progressively declined (currently New York Heart Association [NYHA] class III) despite medical therapy optimization.

Current Medications

The patient was taking torasemide 10 mg daily, bisoprolol 5 mg daily, spironolactone 25 mg daily, enalapril 10 mg twice daily, aspirin 100 mg daily, and insulin.

Current Symptoms

The patient was experiencing dyspnea at rest, orthopnea, and edema of the inferior extremities.

Physical Examination

• BP/HR: 107/60 mm Hg/77 bpm

• Height/weight: 175 cm/72 kg

• Neck veins: Jugular vein distention

• Lungs/chest: Pulmonary crepitations

• Heart: Regular cardiac tones without murmurs

• Abdomen: Soft and painless

• Extremities: Edema of the lower extremities

Laboratory Data

• Hemoglobin: 12.8 g/dL

• Hematocrit/packed cell volume: 38%

• Platelet count: 320 × 10 ³ /µL

• Sodium: 136 mmol/L

• Potassium: 3.8 mmol/L

• Creatinine: 121 mmol/L