Extremely elderly patient in whom the pacing lead was implanted via the femoral vein

We report on an extremely elderly patient in whom we were unable to insert a pacing lead via the subclavian or internal jugular vein because of a superior vena cava obstruction; we instead inserted the pacing lead via the femoral vein. The patient was a 98-year-old male. Thirty-nine years previously, pacemaker implantation was performed for complete atrioventricular block. Afterwards, pacemaker replacement and reimplantation had been performed a total of 15 times. The patient was recently admitted because of pacing failure. Pacemaker replacement was performed, but pacing was not possible because of disconnection of the pacing lead. Insertion of a new pacing lead was attempted via both subclavian veins and the right jugular vein but failed; this approach was abandoned and temporary pacing was done. Superior vena cava obstruction was noted on chest computed tomography (CT), and pacing lead insertion through the superior vena cava was deemed unfeasible. Myocardial electrode implantation was also considered, but general anesthesia was deemed problematic because of the patient's extreme age. A pacing lead was inserted via the right femoral vein, and the generator was implanted in the right lower abdomen. Postoperative pacing was satisfactory.     

Interaction of an implanted pacemaker with a transesophageal atrial pacemaker: report of a case

We report an interaction of a transesophageal atrial pacemaker (TAP) with a permanently implanted pacemaker in a cardiac patient who had undergone ablative therapy for atrial tachyarrhythmia 5 years earlier. The patient’s permanent A-V pacemaker was completely inhibited by the TAP, and there was loss of ventricular contractions and blood pressure. The patient required epicardial A-V pacing to overcome the programmed heart rate of 76 bpm. We describe alternative methods to epicardial pacing. We also recommend close inspection of the chest radiograph, which often can reveal the serial numbers of the implanted pacemaker, as a means of identifying the device’s functions and programming.     

A case report of aortic stenosis complicated with complete atrioventricular block

A case of aortic stenosis complicated with complete atrioventricular block preoperatively was reported. The patient was a 73-year-old woman who had been suffering from dyspnea and fatigability. Preoperative echocardiography revealed severe left ventricular hypertrophy, marked left ventricular-aortic pressure gradient (144 mmHg), and the impairment of left ventricular distensibility. Therefore, DDD pacemaker was implanted in addition to aortic valve replacement. Postoperative cardiac catheterization revealed that cardiac output was increased about 25% by DDD pacing compared with VVI pacing. It is more reasonable to employ DDD pacemaker to the case of which distensibility is impaired.     

Cardiac Pacemaker Infection: Surgical Management With and Without Extracorporeal Circulation

Background. Pacemaker infections are rare, but serious complications of pacemaker therapy. The generator pocket, the pacing leads, or both may be involved.

Methods. We report on 12 patients with infected pacemaker systems. Four patients suffered from localized generator pocket infections, 6 had infected leads, and 2 patients had both. Pacemaker systems were completely removed in all patients. When the infection was limited to the generator pocket, the pacemaker system was removed at the original implantation site. Extracorporeal circulation was employed for the explantation of infected pacing leads.

Results. No complications occurred in patients with localized generator pocket infections. One patient with infected leads who was preoperatively already in a serious clinical condition died of septic shock in the early postoperative period; another patient died of pulmonary complications after tricuspid valve replacement 14 months after pacemaker explantation. No recurrent infections were observed.

Conclusions. Explantation of the complete pacemaker system has proved a reliable method to eradicate infection. Complications have been rare, except in patients in a critically ill state who undergo cardiopulmonary bypass.     

Total removal of infected pacemaker lead under cardiopulmonary bypass in a case of endocarditis, bacteremia and lung abscess

A 60-year-old man, who had undergone implantation of a transvenous pacemaker system on the left chest wall for sick sinus syndrome 19 years ago, was admitted because of endocarditis with septicemia and lung abscess 2 months after reimplantation of the generator. His blood culture revealed Staphylococcus aureus. Following debridement of the infected pacemaker pocket and antibiotics therapy, we tried to remove the pacemaker system under cardiopulmonary bypass 1 month after admission. In intraoperative inspection, the electrodes had become firmly encased with fibrous tissue within the tricuspid valve and the right ventricle. After the operation, antibiotic therapy was performed for 4 weeks. His postoperative course was uneventful. Patients with pacemaker infection should undergo aggressive total removal of the pacemaker system, particularly incase with endocarditis and bacteremia.     

Successful reimplantation of a passive-fixation ventricle lead perforating the chest wall

Delayed perforation of a passive fixed pacemaker lead is a rare complication after pacemaker implantation and is associated with increased morbidity and mortality. We report the case of an 82-year-old patient who presented with a delayed perforation of the right heart wall, the pericardium, and the chest wall by a passive-fixation ventricular lead 14 months after pacemaker implantation. The lead was uneventfully extracted transvenously and repositioned in the right ventricle with good pacing and sensing.     

Treatment of Necrotic Infection on the Anterior Chest Wall Secondary to Mastectomy and Postoperative Radiotherapy by the Application of Omentum and Mesh Skin Grafting: Report of a Case

We report herein the case of a patient who initially underwent right radical mastectomy for breast carcinoma in 1988, followed by left breast-conserving surgery in 1997. On both occasions she was given postoperative radiation therapy of 50 Gy. Repeated dressings and the administration of antibiotics failed to heal ulcerative infected lesions that had formed on the anterior chest wall in early 1998. In 1999, the sternum and surrounding tissue were debrided and the anterior chest wall was reconstructed by omentum transposition and mesh skin grafting. The patient is currently well and alive without any evidence of recurrence of either infection or breast cancer. Received: March 7, 2001 / Accepted: September 11, 2001     

Epicardial atrial pacemaker lead placement after multiple cardiac operations

We describe a simple technique for the implantation of left atrial epicardial pacing leads in children with congenital heart disease who have undergone multiple operations. The pulmonary veins are exposed to reveal the pulmonary venous to atrial confluence using a left thoracotomy. A pacemaker lead is secured to the posterior left atrium inferior to the lower pulmonary vein. This approach provides a reliable site for atrial lead placement without the need for extensive dissection.     

Removal of retained transvenous pacemaker electrodes under cardiopulmonary bypass

A case of breakage and removal of a retained transvenous pacemaker electrode is described. A 22-year-old woman with complete A-V block underwent implantation of a transvenous pacemaker system on the left anterior chest wall in 1989. Three years later, a new generator was implanted on the right chest wall because of local infection of the pacemaker pockets. The old electrodes could not be removed and were left in place. Beginning in 1995, the patient complained of anterior chest pain. A chest roentgenogram revealed that one of the pacemaker electrodes had broken at the right costoclavicular ligament and a fragment was floating in the superior vena vava. The retained electrodes were removed under totl cardiopulmonary bypass. These electrodes had become firmly encased with fibrous tissue within the right ventricle and atrium, but they were easily removed under direct vision duting complete cardiac arrest. The postoperative course was uneventful and the patients had no further complaint.     

A 40-year delayed locoregional recurrence of breast carcinoma following mastectomy

A 90-year-old woman who underwent a left modified radical mastectomy 40 years ago with no further adjuvant treatment presented with a left chest wall mass at the suture line. A biopsy of the mass confirmed that it was invasive ductal carcinoma of the breast. After a negative metastatic work-up, the patient underwent a local resection of the chest wall mass with clear margins. We present here the longest documented delayed recurrence after modified radical mastectomy reported in the literature.     

Extracorporeal shock wave lithotripsy for ureteral stone in patient with implanted cardiac pacemaker: a case report

We report a case of extracorporeal shock wave lithotripsy (SWL) for ureteral stone in patient with implanted cardiac pacemaker. A 68-year-old woman was admitted to our hospital for left back pain due to left single ureteral stone (13 x 7 mm) in 2002. A permanent cardiac pacemaker has been implanted for sick sinus syndrome in 1997. After evaluation for cardiac function and pacemaker function by a cardiologist and a pacemaker technician, SWL (MFL 5000, Dornier) was performed without changing pacemaker mode (DDD mode). Shock waves were incorrectly exposed a few time triggered by arterial pacing amplitude, but no cardiovascular event or malfunction of the pacemaker was occurred during or after SWL. The ureteral stone was successfully fragmented with 2,400 shock waves (24 kV) and the fragments were delivered immediately.     

Pacemaker endocarditis: approach for lead extraction in endocarditis with large vegetations

We present the case of a patient with vegetations on a pacing lead from a pacemaker implanted 13 years previously. A new surgical technique for removal of infected leads was developed to avoid the increased risk of septic pulmonary embolism. The electrode with vegetations was removed without cardiopulmonary bypass using the direct surgical approach described.     

A case report of total removal of infected pacemaker with cardiopulmonary bypass

A successful removal of infected pacemaker with septicemia, pre-DIC state, and pneumonia is reported. A 44-year-old man received transvenous permanent pacemaker implantation through right subclavian region at 42 years of age. Two years and 3 months after implantation an abscess formed around the generator. Since incision and drainage were not effective, the generator was removed after 2 months (another pacemaker was reimplanted at the opposite side), and the initial pacing lead was cut after 3 months of initiation of the infection. But wound healing was not obtained and high fever-up occurred. Arterial blood culture showed septicemia caused by Staphylococcus aureus. He also suffered pre-DIC state and pneumonia. The end of the cut lead had fallen into the right ventricle. After general condition was recovered, the residual lead and the reimplanted pacemaker system were extirpated under cardiopulmonary bypass. And at the same time a new pacemaker system was implanted again. He was in good postoperative course, and he is up and well 8 months after operation.     

Cardiac pacing in premature infants and neonates: steroid eluting leads and automatic output adaptation.

BACKGROUND: Appropriate generator and lead selection as well as techniques of implantation are most important aspects of cardiac pacing in the extremely young patient. Here we report the clinical results using a new technique with automatic output adaptation based on evoked response in combination with steroid-eluting epicardial leads in small children. METHODS: One neonate and 2 premature infants underwent permanent pacemaker implantation because of congenital high-degree atrioventricular block or postoperative complete heart block, respectively. Steroid-eluting epicardial leads and a multiprogrammable pacemaker with automatic output adaptation were used. RESULTS: Intermuscular abdominal generator placement and epicardial suture-fixation of the bipolar lead through a subcostal approach was without complications. Serial follow-up examinations revealed safe and consistent pacemaker function up to 12 months after operation. CONCLUSIONS: The technique represents an excellent alternative for permanent cardiac pacing in extremely small patients. We believe that it provides an increase in functional lifetime of the devices and delays the need for battery replacement with its associated complications in this young patient population.     

Left ventricular pacing through the anterior interventricular vein in a patient with mechanical tricuspid, aortic and mitral valves

Transvenous endocardial pacemaker implantation is contraindicated in patients after mechanical tricuspid valve replacement. A 76-year-old woman who suffered from bradyarrhythmia was implanted with a left ventricular pacing lead through a transvenous coronary vein after aortic, mitral, and tricuspid valve replacements. There were no complications and the stimulation thresholds were stable. The use of coronary vein leads provides a minimally invasive approach, safety, and effective stimulation for patients with a mechanical tricuspid valve.     

Temporary use of an eroded bipolar pacemaker system

Over a 2.5-year period, of 176 bipolar pacemaker procedures, six were complicated by erosion (incidence, 3.4%). One patient was treated whose pacemaker was inserted at another hospital. Time from insertion to presentation ranged from 5 to 23 months. When infection was present, Staphylococcus epidermidis was found to be the offending organism. We have used a staged method for managing this problem. Initially, the bipolar pulse generator was exteriorized and worn suspended around the neck while infection was controlled. A new pacemaker system (catheter and pulse generator) was inserted from the opposite side once infection was controlled. The main advantage of this type of approach is that the old pacing catheter and old bipolar generator can be used as an effective temporary pacing system, while the infection is being controlled thus eliminating the step of inserting a temporary pacing catheter after the eroded generator and catheter have been removed. A temporary pacing catheter is only safe and effective for a few days (perhaps up to a week), and this may not be sufficient time to be sure that infection is locally controlled. In addition, the patient can be ambulatory as the old permanent catheter is not likely to be dislodged easily as compared with a temporary catheter. Follow up ranging from 2 to 23 months has shown this to be an effective method for treating bipolar pacemaker erosion or infection in all instances without further infection or complication.     

Massive hemoptysis due to traction bronchiectasis caused by thoracic radiotherapy 23 years earlier

We reported a 72-year-old woman who had a massive hemoptysis due to traction bronchiectasis in the left upper lobe. The patient underwent left radical mastectomy followed by thoracic radiotherapy for left breast cancer. The chest computed tomography showed traction bronchiectasis in the atrophic left upper lobe and the bronchial angiography showed hypervascularization of bronchial and internal thoracic arteries to the left upper lobe. Left upper lobectomy was performed after bronchial embolization for recurrent massive hemoptysis. Postoperative course was uneventful. Pathologic findings showed non-anatomical but clearly-bordered traction bronchiectasis with hypervascularized bronchial artery in the left upper lobe. These lesions were consistent with the field of the previous radiotherapy. Traction bronchiectasis causing massive hemoptysis should be considered as one of pulmonary sequelae after thoracic radiotherapy.     

Biventricular pacing 18 months after Batista operation

We conducted biventricular pacing in a patient with dilated cardiomyopathy and complete left bundle branch block who had recurrent heart failure and mitral valve regurgitation 18 months after partial left ventriculectomy and mitral valve repair. An epicardial lead was fixed on the left ventricular free wall surgically through a thoracotomy, and the other two leads were implanted transvenously. Biventricular pacing restored contractile synchrony and led to more efficient left ventricular contraction and reductions in mitral regurgitation. Biventricular pacing may produce beneficial effects for patients with the recurrent intractable heart failure associated with cardiomyopathy and complete left bundle branch block after partial left ventriculectomy.     

Late left ventricular perforation by active fixation pacemaker lead implanted in the right ventricular septum

We report a rare case of late left ventricular perforation caused by a migrated pacemaker lead, which had been implanted in the right ventricular septum three months prior. Preoperative computed tomography findings revealed that the tip of the migrated pacemaker lead had perforated the ventricular wall near the intraventricular groove into the anterior chest wall.     

Arteriovenous fistulae complicating cardiac pacemaker lead extraction: recognition, evaluation, and management

Transvenous pacemaker lead extraction has become a commonly performed procedure that is associated with a small but significant risk. We report two cases where lead extraction was complicated by arteriovenous fistulae between branches of the aortic arch and the left brachiocephalic vein. Presenting signs and symptoms included severe chest or back pain, persistent or copious bleeding from the venous puncture site, unexplained hypotension or anemia, superior vena cava syndrome, and signs of central venous hypertension or acute heart failure. One patient whose injury was not recognized immediately and who did not undergo repair died rapidly, whereas the other patient who was diagnosed quickly underwent successful repair. Immediate diagnosis with arteriography and rapid intervention with surgery or percutaneous techniques are indicated and may prevent mortality.