Usefulness of the Active Fixation Quadripolar Left Ventricular Lead for Ratchet Syndrome

A 56-year-old man with a medical history of hemodialysis and ischemic cardiomyopathy complained of twitching. He received cardiac resynchronization therapy with defibrillator implantation 8 months ago. Cannulation into the coronary sinus (CS) from the right side was difficult due to both atria being enlarged (Figure A), and the large size of the targeted coronary vein (Figure B).

Figure.

Fluoroscopic images (A,B,E) and chest X-rays (C,D,F,G). Yellow arrow: tip of LV lead; (B) red arrow: the targeted coronary vein; (E) red arrow: coiled LV lead; (F) red circle: side helix. Images courtesy of Medtronic Japan Co., Ltd. AP, anteroposterior; ASQ, Attain Stability Quad (Medtronic); LAO, left anterior oblique; LV, left ventricular; RAO, right anterior oblique.

Physical examination revealed a body mass index of 27.6 kg/m², and an arteriovenous fistula in the left arm. Compared with images obtained 8 months previously (Figure C), chest X-ray demonstrated that the left ventricular (LV) lead was coiled in the superior vena cava (Figure D). He was diagnosed with ratchet syndrome. When he underwent LV lead re-insertion, only the LV lead was found coiled inside the pocket (Figure E). The Attain Stability Quad (ASQ4798; Medtronic, USA) lead was selected because it can be fixed by screwing (Figure F). Lead dislodgement had not occurred at 10 months after re-insertion (Figure G).

Ratchet syndrome, a rare complication, involves lead dislodgement and retraction due to a ratchet-like movement through the suture sleeve causing a continuous short pull.¹ Risk factors of LV lead dislodgement include older age, obesity, oversized pocket, inadequate sleeve fixation, coronary vein size and angle from the CS, and lead slackness. Moreover, implantation on the dominant hand side increases the risk of ratchet syndrome. Previous studies report that the ASQ had fewer postoperative LV lead-related complications than non-ASQ leads.^2,3 The use of the ASQ in patients with risk factors for ratchet syndrome may prevent LV lead dislodgement.

References

• 1.   Morales JL, Nava S, Márquez MF, González J, Gómez-Flores J, Colín L, et al. Idiopathic lead migration: Concept and variants of an uncommon cause of cardiac implantable electronic device dysfunction. JACC Clin Electrophysiol 2017; 3: 1321–1329.
• 2.   Wakamiya A, Ishibashi K, Oka S, Miyazaki Y, Ueda N, Nakajima K, et al. Clinical usefulness of the Active Fixation Quadripolar left ventricular lead compared with the passive fixation quadripolar lead in cardiac resynchronization therapy. Circ J 2024; 88: 1425–1431.
• 3.   Robertson C, Duffey O, Tang PT, Fairhurst N, Monteiro C, Green P, et al. An Active Fixation Quadripolar left ventricular lead for cardiac resynchronization therapy with reduced postoperative complication rates. J Cardiovasc Electrophysiol 2022; 33: 458–463.