Interaction Between Atrial Pacing Lead and Epicardial Ventricular Wire Resulting in Unintended Ventricular Capture by Pacemaker Atrial Output

A 65-year-old man with a history of coronary artery disease underwent coronary artery bypass grafting in 1997 and 1998. He also received a permanent dual chamber pacemaker implantation during the second bypass surgery for complete heart block. He presented a year later to our pacemaker clinic for follow-up. Initial ECG showed ventricular capture by pacemaker atrial output (bottom tracings, left side). When the atrial output was decreased by 0.5V, normal atrial and ventricular pacemaker function was restored (bottom tracings, right side). A chest X-ray revealed an active fixation atrial lead implanted to the right atrium and a passive fixation lead to the ventricle. There was no apparent insulation failure of either lead by X-ray or by impedance measurements. An epicardial pacing lead implanted during bypass surgery for temporary postoperative pacing was not completely removed. The proximity between the retained epicardial wire and the screw of the active fixation atrial lead (arrow) support the hypothesis that the atrial output was conducted by the retained epicardial wire into the ventricles, resulting in unintended ventricular capture by the atrial output. However, we could not exclude the possibility that the atrial lead directly resulted in ventricular capture due to its proximity to the AV grove.     

Epicardial Versus Endocardial Pacemakers in the Pediatric Population: A Comparative Inquiry

Background: Most children in need of cardiac pacemakers remain dependent on the function of the permanent from childhood to adulthood. We sought to evaluate and compare the function between epicardial and endocardial pacemakers in pediatric groups with different conditions. Methods: Between 2012 and 2018, this single-canter study evaluated 44 pediatric patients with indications for epicardial or endocardial pacemakers. Results: The 2 groups, at a median age of 5 (0.1–16) years, were compared concerning the characteristics of the leads used (n = 80: bipolar, unipolar, steroid-eluting, and non–steroid-eluting), survival data, and complications. The reason for pacemaker implantation was congenital complete heart block in 11 (25%) cases and postoperative heart block in 33 (75%) cases. The commonest congenital heart disease accompanied by postoperative block was the ventricular septal defect. In the endocardial lead group, the mean ventricular pacing threshold immediately after the implantation and during the follow-up was less than that in the epicardial lead group (0.75 vs. 0.81 V; P = 0.01 and 0.8 vs. 2.4 V; P = 0.001). During the follow-up, the mean battery longevity was better in the endocardial group (last visit: 6.7 endocardial vs. 3.3 years epicardial). Lead failure was commoner in the epicardial pacemaker, and chronic high-pacing threshold pattern was seen in 14 patients in this group. After 3 years, freedom from lead failure was 94% and 63% in the endocardial and epicardial leads. Conclusions: Pacemakers with endocardial bipolar steroid-eluting leads showed better lead characteristics regarding survival and battery longevity than epicardial pacemakers without these lead characteristics. An appropriate pacemaker type should be selected based on the patient’s condition.     

Permanent left ventricular pacing from the great cardiac vein of a patient with artificial tricuspid and mitral valves--a case report

Transvenous placement of a right ventricular pacemaker lead through the artificial tricuspid valve is a known contraindication, and in this situation, epicardial pacemaker implantation is the procedure of choice. However, permanent pacemaker implantation is a subject for debate when the use of the epicardial route is impossible. This report describes alternate transvenous routes for a pacemaker lead in a patient with an artificial tricuspid valve and mitral valve in whom the epicardial lead and pacemaker generator must be removed because of resistant infection.     

Benefit of the steroid electrode

A permanent pacemaker was implanted in an 80-year-old patient with complete heart block. The electrode had to be changed six times (endocardial, five and epicardial, one) due to a progressive rise in threshold with recurrent exit block. A porous, steroid eluting, endocardial electrode was implanted and has given 27 months of excellent service. This lead may be ideal for patients who have a progressive increase in threshold after repeated electrode implantation.     

Conduction disturbance and pacemaker therapy in patients with corrected transposition of the great arteries.

We observed 4 adult patients with corrected transposition of the great arteries (CTGA) who developed complete atrioventricular block: of 4 patients, 2 received endocardial pacemakers (DDD mode), 1 an epicardial pacemaker (VVI mode), and 1 patient did not have a permanent pacemaker implantation. Endocardial lead fixation in the systemic venous atrium and ventricle is adequate to provide permanent electrode stability in patients with CTGA.     

Cardiac strangulation from epicardial pacemaker: early recognition and prevention

Cardiac strangulation from epicardial pacemaker leads is a rare event that can be difficult to recognise and can cause serious complications such as cardiac failure or death. We describe a 3-year-old girl who received an epicardial pacing system as a neonate for complete congenital cardiac block and developed cardiac strangulation from the leads. The clinical presentation modes are reviewed and technical aspects for lead and generator positioning are discussed.     

ST Segment Elevation in One Lead: A Case Report

Background: We describe an unusual finding in an electrocardiogram showing ST‐segment elevation not related to coronary artery stenosis, pericarditis, bundle branch block, or other well known disorders. Case Presentation: A 60‐year‐old African American woman admitted for elective coronary artery bypass graft surgery. A temporary pacemaker with pacing wires was placed intraoperatively for prevention and treatment of postoperative bradyarrhythmia. One day following uneventful surgery, her electrocardiogram demonstrated marked ST segment elevation confined to lead V₆. These changes were comparable to tracings obtained from direct epicardial electrocardiogram, due to contact between the V₆ electrode and the temporary pacemaker ventricular lead wire. Conclusion: Current‐of‐injury patterns are represented on surface electrocardiogram by deviations of the ST segment from the isoelectric baseline. The pacing wire causes direct localized epicardial current‐of‐injury, affecting the action potential and the resting membrane potentials of cardiomyocytes. Our case report demonstrates epicardial current‐of‐injury pattern obtained via surface rather than epicardial electrocardiogram, with surface leads as surrogates of epicardial tracing. Measurement of ST‐segment shifts from the epicardial electrocardiogram has been shown to provide a more sensitive measurement of ischemia when compared to surface precordial ECG.     

Pacemakers in children: an update

This report reviews recent pacemaker technological advances as they apply to infants, children, and adolescents. Indications for pacemaker implantation in children have evolved since the 1984 Joint Task Force Guidelines. Recent data show that pacemaker implantation should be strongly considered in patients who have (1) asymptomatic congenital complete AV block with a mean heart rate less than 50 beats/min or other evidence of junctional instability; (2) congenital AV block with long QT interval; or (3) congenital long QT syndrome with bradyarrhythmias, or when conventional beta-blocker therapy is unsuccessful. Permanent pacemaker implantation is not necessarily an effective prophylactic measure against sudden death in patients following their operation who are receiving drug therapy for atrial tachyarrhythmias, and so is not absolutely indicated. New developments in lead technology have made transvenous lead systems more feasible for pediatric use. Because epicardial leads are required for small infants and for cosmetic reasons in some older children, design improvements are needed to enhance epicardial lead performance. Rate-responsive pacing is an acceptable alternative to dual-chamber pacing for augmenting exercise tolerance, and for children with sinus node dysfunction it is the preferred pacing mode. Pacemakers with automatic antitachycardia capabilities and with noninvasive electrophysiology features are valuable in children with atrial tachyarrhythmias. New data suggest that chronic atrial pacing also may be effective in controlling atrial tachyarrhythmias. New developments in pacemaker systems for the young parallel those for the older population, but differences between adult and pediatric patients demand ongoing increased participation by pediatric cardiologists.     

Permanent pacemaker therapy in corrected transposition of the great arteries: analysis of site of lead placement in 40 patients

A retrospective analysis of 58 pacemaker leads in 40 patients with corrected transposition of the great arteries (CTGA) was made to compare the function of endocardial and epicardial leads. Extensive trabeculations of the normal right ventricle are generally thought to be essential for endocardial pacemaker lead stability. Because the systemic venous ventricle in CTGA lacks an extensive trabecular network, there has been concern that transvenous lead placement may result in a high rate of dislodgement. Epicardial leads have been assumed to be more reliable in these patients. Forty-seven epicardial and 11 endocardial leads were placed in 40 patients with CTGA who required permanent pacemaker therapy for symptomatic bradycardia. Of 13 episodes of epicardial lead malfunction in 158 patient-years, 3 were due to lead fracture and 10 to high thresholds. Surgery was required to correct the lead malfunction in 12 instances and thoracotomy was necessary for new lead placement in 6 patients. During 26.2 patient-years, there were 2 episodes of endocardial lead failure due to a high acute threshold and perforation. There were no instances of endocardial lead dislodgement. No association between type of failure and lead design was noted for either endocardial or epicardial leads. Actuarial analysis of survival revealed no significant differences in reliability between endocardial and epicardial leads. Endocardial lead fixation in the systemic venous ventricle in patients with CTGA is adequate to prevent lead dislodgement and preferable to epicardial lead placement because thoracotomy is avoided.     

Pacing in children.

Fourteen children had a permanent pacemaker implanted between May 1967 and July 1983. Postoperative complete heart block was the indication in nine cases, congenital complete heart block in three, and sick sinus syndrome in two. Two patients died, one suddenly and one after aortic valve replacement. A total of 48 pulse generators were implanted; five patients were given an isotopic pacemaker. Twelve patients had epicardial leads implanted initially, and two received a transvenous endocardial system. The lead system implanted initially remained without malfunction in only seven patients. In the other seven patients 20 lead malfunctions occurred. Psychological maturity and physical development seemed to be normal in all 14 children. Improvement in equipment and technique will improve the outlook for paced children in the future.     

Pacing in children

Fourteen children had a permanent pacemaker implanted between May 1967 and July 1983. Postoperative complete heart block was the indication in nine cases, congenital complete heart block in three, and sick sinus syndrome in two. Two patients died, one suddenly and one after aortic valve replacement. A total of 48 pulse generators were implanted; five patients were given an isotopic pacemaker. Twelve patients had epicardial leads implanted initially, and two received a transvenous endocardial system. The lead system implanted initially remained without malfunction in only seven patients. In the other seven patients 20 lead malfunctions occurred. Psychological maturity and physical development seemed to be normal in all 14 children. Improvement in equipment and technique will improve the outlook for paced children in the future.     

Permanent pacing using a coronary sinus lead in a patient with univentricular physiology: an extended application of biventricular pacing technology.

In the past, patients requiring permanent pacing with difficult right ventricular (RV) access were usually subjected to epicardial pacing by a surgical approach. This report describes a young patient with univentricular physiology following repeated palliative surgery for complex congenital heart disease. The patient had symptomatic complete heart block and a dual chamber pacemaker with transvenous atrial and ventricular leads was implanted successfully. The ventricle was paced through the posterolateral cardiac vein with a lead specially designed for cardiac resynchronization therapy. This case illustrates an extended application of the recently developed coronary sinus lead in selected patients, when conventional RV endocardial pacing is impossible.     

Cardiac resynchronisation therapy versus dual site right ventricular pacing in a patient with permanent pacemaker and congestive heart failure.

A 46-year-old male patient who had long-term right ventricular (RV) pacing for symptomatic complete heart block, initially by an epicardial, later with an endocardial pacing lead at the RV apex, developed congestive heart failure (CHF) and chronic atrial fibrillation 7 years following the pacemaker implantation and was medically treated. During follow-up, his pacemaker was upgraded to a cardiac resynchronisation therapy (CRT) device, because of uncontrolled CHF symptoms, New York Heart Association (NYHA) functional class IV, while on drugs. The patient's symptomatic status improved to NYHA functional class II with CRT. After 17 months of CRT, the battery became depleted, because of the high capture threshold of the left ventricular lead. The patient was then given dual site RV pacing (RV outflow tract+RV apex) in place of CRT, which showed similar efficacy at 12 weeks follow-up.     

Right ventricular dysplasia with complete atrioventricular block: Necessity and limitation of left ventricular epicardial pacing

This paper reports a case of right ventricular dysplasia, in which the patient presented with atrioventricular block and was followed for more than 8 years under left ventricular epicardial pacing. Five years after first epicardial pacemaker implantation, loss of capture occurred. Replacement of the epicardial leads was performed.     

Cardiac strangulation in a neonatal case: a rare complication of permanent epicardial pacemaker leads

A newborn female underwent pacemaker implantation with epicardial pacing leads for the treatment of bradycardia caused by congenital atrioventricular block. At 10 months after pacemaker implantation, she was admitted with congestive heart failure. The epicardial leads were seen to encircle the heart, and myocardial ischemia was suggested. During cardiac catheterization she collapsed: emergency operation was performed, but she died on postoperative day 6.     

Intraperitoneal migration of epicardial pacemakers

Intraperitoneal migration of epicardial leads and abdominally placed generators is a potentially serious complication. We report the case of an 83-year-old man who experienced intraperitoneal migration of an epicardial pacing system and consequent small-bowel obstruction. Laparotomy was required in order to free constrictive lead adhesions. The patient's postoperative recovery was satisfactory after the placement of a new pacemaker generator in the abdominal wall. Predisposing factors are analyzed and the literature is reviewed in order to clarify the mechanisms of sequelae associated with the migration of epicardial pacemakers from the abdominal wall. To the best of our knowledge, this is the 1st report of pacemaker migration having caused bowel obstruction that required urgent laparotomy in an adult.     

Endocavitary implantation of a permanent pacemaker in the contralateral side of right pneumonectomy: a case report

The definitive endocardial stimulation is easy to install, allows a stable position of the leads, and a satisfactory stimulation thresholds for a long period. The epicardial approach is reserved for some rare indications including infectious contexts. The endocardial approach has been considered for a 67 years man with a complete AV block and an atrial fibrillation. This patient had undergone a right pneumonectomy 15 years before. A VVIR pacemaker has been implanted successfully by an internal jugular vein approach, and connected to a passively fixed unipolar lead. Because of the right ventricle deformation which made it unrecognizable, even by angiography means, we had to face major difficulties to position the lead. The epicardial approach should be considered even if a direct unique lung controlateral approach is easier than homolateral, because it allows us a quick ventricular access under the view control.     

Unusual case of colonized pacemaker lead presenting with endocarditis, hemoptysis and tricuspid valve stenosis

The present report is the first to describe a case of hemoptysis caused by an endocardial pacemaker lead. In addition, the patient presented with endocarditis and tricuspid valve stenosis. Aggressive treatment consisted of surgical extraction of two pacemaker leads and one pacemaker battery, replacement of the tricuspid valve and implantation of a DDD-R epicardial pacemaker.     

Pacing in preterm with hydrops fetalis due to congenital complete heart block

Hydrops fetalis due to congenital complete heart block (CCHB) is a rare condition. The outcome of the preterm fetus with hydrops fetalis due to CCHB is poor, and is frequently associated with significant morbidity and mortality. The management of this condition is difficult. We report our experience in a hydropic preterm using staged pacing by applying left ventricular epicardial pacing with a temporary pacemaker and subsequently, left ventricular epicardial pacing with a permanent pacemaker.     

Placement of permanent epicardial pacemaker in a newborn with congenital complete AV block

Isolated congenital atrioventricular block is reported in one out of 20,000 live births. The optimistic view on the prognosis and indications for permanent pacing have been modified in the last 35 years. The purpose of this report is to present a prenatally diagnosed case, outlining the surgical technique for permanent pacing. The infant was a male born by cesarean section, weighted 3030 grs and had a structurally normal heart. His ECG showed complete AV block with narrow QRS, atrial rate was 140 and ventricular rate was 55. We implanted a epicardial pacemaker VVIR by midline laparatomy. The lead was unipolar 35 cms long screw-in type and was placed in the right ventricle through the xiphoid process. The pacemaker was placed in a GoreTex bag and fixed intraperitoneal to the abdominal wall. The infant did well after the procedure and he was discharged in good condition one week later. We conclude that it is appropriate to implant a permanent pacemaker in these patients with low ventricular rate thus reducing the risk of sudden cardiac death. The surgical technique is safe and makes easy the generator replacement.