title: Inadvertent transposition of defibrillator coil terminal pins causing inappropriate ICD therapies.
abstract: We report the case of a 65-year-old man with chronic atrial fibrillation (AF) and severe ischemic cardiomyopathy who underwent implantation of a prophylactic single-chamber implantable cardioverter-defibrillator (ICD). The patient experienced inappropriate ICD therapies due to oversensing of pectoral muscle myopotential secondary to reversal of the defibrillator coil terminal pins in the ICD header. Recognizing this possibility is important to avoid misinterpretation of spontaneous oversensing as hardware failure (e.g., lead fracture or insulation breech) and potentially unnecessary ICD system surgical intervention, including lead extraction.
authors.affiliation: Prairie Cardiovascular Consultants, Southern Illinois University, 747 North Rutledge, Springfield, IL 62702, USA. zissa@prairieheart.com
authors.forename: Ziad F
authors.initials: ZF
authors.lastname: Issa
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000628:therapy*; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D006801:Humans; D008297:Male; D019300:Medical Errors