(1132) A Rare Case of Massive Hemoptysis due to a Pseudoaneurysm/Fistula Formation From an Epicardial ICD

Introduction: Implantable cardioverter devices (ICD) have existed for a long time, however, there is a lack of reports regarding complications of ICD placement. This case report demonstrates the development of a left ventricular pseudoaneurysm with bronchial-ventricular fistula.

Description: The patient is a 75-year-old female with a history of ICD placement in 1992, complicated by a lead fracture requiring transvenous ICD placement in 2012. She experienced venous thromboembolic disease complicated by hemoptysis and cardiac arrest needing IVC filter placement and reduced Eliquis dosing. She was admitted for hemoptysis. Computerized tomography angiography (CTA) chest showed retained epicardial pacer leads with possible erosion into the left ventricle without active contrast extravasation. However, there was evidence of active bleeding on bronchoscopy, so the right and left bronchial arteries were empirically embolized and a left main bronchial blocker was placed. The surgical evaluation revealed erosion of the leads into the left ventricle, creating an open defect with a pseudoaneurysm with a fistula to the left lung. Following surgical repair, she made a full recovery.

Discussion: These days transvenous ICD is the preferred modality, though epicardial ICD remains an option for complicated cases. The NCDR registry reports a 3.08% rate of major complications and a 1.02% rate of epicardial ICD lead displacement. However, they may appear sooner and with a higher rate​1​. Examples included bronchocutaneous fistula​2​, arteriovenous fistula​3,4​, and intraventricular lead migration​5​. To our knowledge, this case study is the first to demonstrate a rare but high mortality risk complication that occurred 20 years after the initial epicardial lead placement and 13 years after the lead fracture. Therefore, a high suspicion for pseudoaneurysm formation should be maintained especially with recurrent hemoptysis in the setting of retained old pacemaker leads. In the absence of consensus regarding this diagnosis, prompt evaluation with imaging such as CT angiography and transesophageal ECHO along with the involvement of a multidisciplinary team (intensivist, pulmonologist, cardiothoracic surgery, IR) is crucial for timely management and avoiding bad outcomes.