Delayed Cardiac Perforation by Defibrillator Lead Placed in the Right Ventricular Outflow Tract Resulting in Massive Pericardial Effusion

A 76‐year‐old man received a dual‐chamber implantable cardioverter defibrillator (ICD), with the defibrillator lead positioned within the right ventricular outflow tract. The lead parameters at the time of implantation were satisfactory and the postprocedure chest X‐ray showed the leads were in place. The patient was cardioverted from atrial fibrillation during defibrillation threshold testing and commenced on anticoagulation immediately. One month post implantation, he experienced multiple ventricular tachycardia episodes all successfully treated with antitachycardia pacing and shocks by his ICD, but he fell and hit his chest against a hard surface during one of these attacks. He developed a massive pericardial effusion and computed tomography confirmed cardiac perforation by the defibrillator lead. Pericardiocentesis was performed and the defibrillator lead replaced with a different model positioned at the right ventricular apex. The patient made an uneventful recovery. The management and avoidance of delayed cardiac perforation by transvenous leads were discussed.     

癌性心包积液的超声心动图表现

本文报道4例经病理证实为癌性心包积液所致的“心脏摇摆综合征”的超声心动图表现,并对此现象产生的机理进行了讨论。本组病例观察表明,大量心包积液出现心脏摇摆综合征,特别是在成年人出现心脏机械性交替合并电交替的典型“心脏摇摆综合征”时,应高度怀疑癌性心包积液的可能。     

Perforation of the Right Ventricular Free Wall by an Active Fixation Transvenous Cardioverter Defibrillator Lead

A 58-year-old patient with dilated cardiomyopathy underwent implantable cardioverter defibrillator (ICD) implantation. The postoperative course was complicated by perforation of the right ventricular free wall by the active fixation transvenous ICD lead. The type of ICD lead and the type of organic heart disease are apparently important risk factors for perforation.     

心包积液67例临床表现的多样性及病因分析

目的回顾以心包积液为主要临床表现而就诊的病例,分析其病因及治疗预后。方法总结近20年来以心包积液为主要临床表现而就诊的患者共67例。结果病因构成：肿瘤性心包积液30例,占首位,其他依次是结核性心包积液16例,心力衰竭致心包积液（心包积水）8例．非特异性心包积液6例,甲状腺机能减退症心包积液4例,系统性红斑狼疮心包积液3例。病情预后与病因明显相关,但诊疗不及时可使病情恶化。结论肿瘤性心包积液在以心包积液为首诊的患者中的比例有明显升高趋势,目前为首要发病因素,且无明显年龄分布特点,对反复发作的心包积液需积极随访检查除外恶性肿瘤。     

Instantaneous Lead Entrapment: An Unusual Complication of Nonthoracotomy Implantation of an Endocardial Defibrillation Lead

Nonthoracotomy implantation of implantable cardioverter defibrillators is performed with transvsnous leads that are similar to pacemaker leads and are subject to the same potential problems. We report an unusual complication of lead placement in which an electrode immediately became entrapped in the superior rim of the tricuspid valve, resisting all efforts at removal.     

Safety of Pacemaker Implantation in Patients with Transvenous (Nonthoracotomy) Implantable Cardioverter Defibrillators

While several reports bave documented the safety of implantation of transvenous pacemakers in patients with epicardial patch-based impiantable cardioverter defibrillators (ICDs), the implantation of transvenous pacemakers in patients with transvenous (nonthoracotomy) ICDs has not been well-descrihed. We present three patients with transvenous ICDs who subsequently underwent implantation of transvenous pacemakers without complication. Technical considerations and a testing protocol for detection of pacemaker-ICD interactions are discussed.     

Delayed ICD lead cardiac perforation: comparison of small versus standard-diameter leads implanted in a single center

Background: An increased risk of delayed cardiac perforation (DCP) with active‐fixation small‐diameter ICD leads has recently been reported, especially with regard to the St. Jude Riata lead (St. Jude Medical, Sylmar, CA, USA). Few data on the risk of DCP in small versus standard‐diameter leads implanted in a single high‐volume center are available. Moreover, no data on the performances of St. Jude's new small‐diameter Durata lead are as yet available. The aim of this study was to assess the incidence of DCP in small versus standard‐diameter leads implanted in our center. Methods: Between January 2003 and October 2009, 437 small‐diameter leads (190 Medtronic Sprint Fidelis [Medtronic Inc., Minneapolis, MN, USA], 196 Riata, 51 Durata) and 421 standard‐diameter (>8 Fr) leads were implanted. Results: After a median follow‐up of 421 days seven of 858 (0.8%) patients experienced DCP. The incidence of DCP was higher in patients with small‐diameter leads than in those with standard‐diameter leads (1.6% vs 0%, P = 0.01). No cases of DCP occurred among 371 passive‐fixation leads versus 1.4% of events among active‐fixation leads (P = 0.02). The incidence of DCP was 2.5% in Riata, 1% in Sprint Fidelis, 0% in Durata, and 0% in standard‐diameter leads (P < 0.01 for Riata vs standard‐diameter leads). Conclusions: Small‐diameter active‐fixation ICD leads are at increased risk of DCP, a finding mostly due to the higher incidence of events in the Riata family. By contrast, passive‐fixation small‐diameter leads and standard‐diameter leads appear to be safe enough regarding the risk of DCP. Our preliminary data suggest that the new Durata lead is not associated with an increased risk of DCP. (PACE 2011; 34:475–483)     

Pneumothorax: An Unusual Cause of ICD Defibrillation Failure

We describe two patients with defibrillation failure of implantable cardioverter defibrillators (ICDs) resulting from large left pneumothoraxes following subclavian vein puncture during the implantation. Following pneumothorax drainage, low defibrillation thresholds (DFTs) were attained without further manipulations. The absence of other signs and symptoms of pneumothorax and the presence of satisfactory pacing function during the procedure, resulted in a significant delay in diagnosis. Pneumothorax should be included in the differential diagnosis when unexpected high DFTs are found during ICD implantation or predischarge testing. This complication is avoidable by a different surgical approach, cephalic vein cutdown.     

Atrial Lead Dysfunction: An Unusual Feature of Hypothyroidism

Hypothyroidism is known to have a multitude of cardiac electrophysiologic effects, including bradycardia, atrioventricular block, prolonged QT interval, and elevated ventricular pacing thresholds. We report the case of a 36‐year‐old woman who presented with isolated dysfunction of her atrial pacemaker lead, which reversed with thyroid hormone replacement.     

Symptomatic Pericardial Disease Associated with Patch Electrodes of the Automatic Implantable Cardioverter Defibrillator: An Underestimated Complication?

Constrictive pericarditis can be associated with ICD patch electrodes. During a mean follow-up of 24 months, in a population of 35 patients who received ICDs with a patch electrodes configuration, we identified three patients with clinical and hemodynamic signs compatible with this event. Patient 1, a 35-year-old male, underwent implantation of an ICD because of a primary electrical disease complicated by cardiac arrest. Fourteen months later he complained ofexertional dyspnea without any signs of heart failure. Right heart catheter- ization showed high filling pressures and diastolic dip and plateau in pressure curves. Thoracotomy and pericardia! exploration were performed. Three months after removal of the patches and insertion of an endocardial lead system, the patient had normal respiration. Patients 2 and 3, who suffered from coronary heart disease without heart failure, exhibited a hemodynamic profile suggestive of constrictive pericarditis: in one patient, 10 months after ICD implantation, associated with right heart failure; and in the other, 18 months after ICD implantation with left heart failure. Patch electrodes were removed in these two patients and replaced by endocardial lead electrodes with subsequent clinical improvement. It is concluded that constrictive pericarditis related to epicardial patch is not an uncommon occurrence during ICD therapy and should be considered in patients who show clinical signs of cardiac decompensation.     

Low-Pressure Pericardial Tamponade: Case Report and Review of the Literature

Background

Focused cardiac ultrasound (FoCUS) is accurate for determining the presence of a pericardial effusion. Using FoCUS to evaluate for pericardial tamponade, however, is more involved. Many experts teach that tamponade is unlikely if the inferior vena cava (IVC) shows respiratory variation and is not distended.

Hemothorax Associated with Anticoagulation after Placement of Implantable Cardioverter Defibrillator: Possible Similarity to Postinfarction Dressler''s Syndrome

Massive hemothorax developed after placement of an implantable cardioverter defibrillator (ICD) in two patients who received postoperative anticoagulants. The possible relationship of this complication to polyserositis after ICD implantation is discussed as are the possible adverse sequelae of early anticoagulation after ICD implantation.     

Prospective Randomized Comparison of the Safety and Effectiveness of Placement of Endocardial Pacemaker and Defibrillator Leads Using the Extrathoracic Subclavian Vein Guided by Contrast Venography Versus the Cephalic Approach

CALKINS, H., et al. : Prospective Randomized Comparison of the Safety and Effectiveness of Placement of Endocardial Pacemaker and Defibrillator Leads Using the Extrathoracic Subclavian Vein Guided by Contrast Venography Versus the Cephalic Approach. The purpose of this prospective randomized study was to compare the safety and efficacy of the cephalic approach versus a contrast-guided extrathoracic approach for placement of endocardial leads. Despite an increased incidence of lead fracture, the intrathoracic subclavian approach remains the dominant approach for placement of pacemaker and implantable defibrillator leads. Although this complication can be prevented by lead placement in the cephalic vein or by lead placement in the extrathoracic subclavian or axillary vein, these approaches have not gained acceptance. A total of 200 patients were randomized to undergo placement of pacemaker or implantable defibrillator leads via the contrast-guided extrathoracic subclavian vein approach or the cephalic approach. Lead placement was accomplished in 99 of the 100 patients randomized to the extrathoracic subclavian vein approach as compared to 64 of 100 patients using the cephalic approach. In addition to a higher initial success rate, the extrathoracic subclavian vein medial approach was determined to be preferable as evidenced by a shorter procedure time and less blood loss. There was no difference in the incidence of complications. In conclusion, these results demonstrate that lead placement in the extrathoracic subclavian vein guided by contrast venography is effective and safe. It was also associated with no increased risk of complications as compared with the cephalic approach. These findings suggest that the contrast-guided approach to the extrathoracic portion of the subclavian vein should be considered as an alternative to the cephalic approach.     

Recurrent pericardial chest pain: a case of late right ventricular perforation after implantation of a transvenous active-fixation ICD lead

A 36-year-old woman with a history of recurrent syncopal episodes presumably due to ventricular tachyarrhythmia in mitral valve prolapse underwent implantation of a transvenous ICD system. During a 23-month follow-up, she developed recurrent pericardial chest pain with pericardial friction rub. The first episode of chest pain occurred without any detectable change in pacing or sensing parameters. The second episode was associated with an increase in pacing threshold and drop in intracardiac signal amplitude. Right ventricular perforation was suspected fluoroscopically and confirmed by right ventriculography. This case report emphasizes the key steps in the diagnosis of this rare complication of an ICD implantation.     

An Unusual Cause of Carotid Sinus Syndrome: Multiple Symmetric Lipomatosis

A 45-year-old man with multiple symmetric lipomatosis suffered recurrent syncope attributed to carotid sinus syndrome caused by extrinsic compression of the carotid body by the lipomatous masses. Surgical removal reduced but did not stop syncope, which was then controlled by implantation of a DDD pacemaker.     

Oozing from the pericardium as an etiology of cardiac tamponade associated with screw-in atrial leads

Screw-in atrial pacing leads are widely used. Cardiac tamponade is a complication. An 81-year-old woman with advanced atrioventricular block underwent permanent pacemaker implantation and subsequently developed cardiac tamponade. At surgery, the lead-tip screw was found penetrated through the right atrium but not through the pericardium. The source of bleeding was confirmed to scratching the inner pericardial membrane by the screw tip. Although cardiac tamponade due to perforation and leakage is known, tamponade caused by the trauma of an atrial screw on the pericardium with resultant ooze is less well described.