Management of the Patient With Implantable Cardioverter-Defibrillator Lead Failure

52-year-old man was brought to the emergency department because of multiple implantable cardioverter-defibrillator (ICD) shocks. His existing dual-chamber pacemaker was upgraded from a biventricular ICD 4 years ago. The ECG in the emergency department showed sinus tachycardia with left bundle-branch block at a rate of 135 bpm. In the emergency department, the patient received 5 additional shocks without a change in rhythm. A donut magnet was placed over the ICD. Interrogation revealed evidence of a lead fracture, and tachycardia therapies were disabled. The high-voltage lead was a Medtronic Sprint Fidelis ICD lead. Admission to the hospital was recommended for definitive correction of his problem.This case illustrates the most common presentation of an ICD lead failure and the resulting management challenges. Lead failure is typically thought of as an intrinsic design or construction defect leading to an adverse clinical event. However, any adverse clinical event mediated through malfunction of an ICD lead represents lead failure. An ICD lead failure can occur in any patient, even with leads that have a proven record of reliability.The overall incidence of ICD lead failure is difficult to assess because of its underreporting and the absence of strict reporting requirements. Random component failures in individual patients are especially difficult to quantify, but some studies suggest a failure rate of ≈0.58%/y among modern ICD leads.1 Leads that have undergone manufacturer advisory or Food and Drug Administration alerts have a much higher incidence of failure. Examples of ICD leads with high failure rates include the Guidant Endotak DSP (model 0125) and the Medtronic Transvene (model 6936). The 6936 lead had a 90% survival rate at 4 to 5 years and a nearly 60% survival rate at 8 to 9 years. Therefore, lead failure rates are not linear over time. The recent recall of the Medtronic …