An approach to ablate and pace:AV junction ablation and pacemaker implantation performed concurrently from the same venous access site

BACKGROUND: Atrioventricular junction (AVJ) ablation combined with permanent pacemaker implantation (the "ablate and pace" approach) remains an acceptable alternative treatment strategy for symptomatic, drug-refractory atrial fibrillation (AF) with rapid ventricular response. This case series describes the feasibility and safety of catheter ablation of the AVJ via a superior vena caval approach performed during concurrent dual-chamber pacemaker implantation. METHODS: A total of 17 consecutive patients with symptomatic, drug-refractory, paroxysmal AF underwent combined AVJ ablation and dual-chamber pacemaker implantation procedure using a left axillary venous approach. Two separate introducer sheaths were placed into the axillary vein. The first sheath was used for implantation of the pacemaker ventricular lead, which was then connected to the pulse generator. Subsequently, a standard ablation catheter was introduced through the second axillary venous sheath and used for radiofrequency (RF) ablation of the AVJ. After successful ablation, the catheter was withdrawn and the pacemaker atrial lead was advanced through that same sheath and implanted in the right atrium. RESULTS: Catheter ablation of the AVJ was successfully achieved in all patients. The median number of RF applications required to achieve complete AV block was three (range 1-10). In one patient, AV conduction recovered within the first hour after completion of the procedure, and AVJ ablation was then performed using the conventional femoral venous approach. There were no procedural complications. CONCLUSION: Catheter ablation of the AVJ can be performed successfully and safely via a superior vena caval approach in patients undergoing concurrent dual-chamber pacemaker implantation.     

Percutaneous treatment for pacemaker-associated superior vena cava syndrome

Superior vena cava (SVC) obstruction is an uncommon but serious complication associated with permanent pacemaker implantation. The mechanical stress associated with pacemaker wires may lead to vessel wall inflammation, fibrosis, and thrombus formation, and ultimately to venous stenosis and occlusion. The surgical treatment of pacemaker related SVC syndrome requires thoracotomy and carries significant morbidity. This article illustrates the authors' initial experience with a "one-step" percutaneous approach for this problem, consisting of percutaneous retrieval of a pacemaker system, followed by venous revascularization with angioplasty and stenting, and installation of a new pacemaker device.     

Transarterial Permanent Pacing of the Left Ventricle

Clinical evaluation of a 64-year-old male patient with a permanent pacemaker showed a right bundle branch block in his ECG that led to the suspicion of catheter misplacement. A two-dimensional echocardiogram and bilateral venogram demonstrated that the pacemaker lead was not in the venous system and that its course was from the axillary artery to the left ventricle passing through the aortic valve. Thirty-three days after implant, replacement of the pacemaker lead through the venous system to stimulate the right ventricular endocardium was performed. At 7 month follow-up the patient has had no complication from his previous arterial pacemaker implantation.     

Biofilms on indwelling vascular catheters.

BACKGROUND AND METHODS: Some bacteria have a natural tendency to adhere to available surfaces and to form biofilms. Biofilms have been demonstrated on right heart flow-directed catheters, endocardial pacemaker leads, urinary catheters, and other medical devices. In this study, we examined arterial and central venous catheters that had been in place in ICU patients between 1 and 14 days for the presence of bacterial biofilms by scanning electron microscopy, transmission electron microscopy, and a special scraping/sonication bacterial recovery technique. The data taken from these processes were compared with skin entry site swabs and blood cultures and correlated with patient data on infection, bacterial colonization, and antibiotic use. RESULTS: Extensive biofilm formation was demonstrated by scanning electron microscopy on all 42 arterial and 26 central venous catheters. Bacteria were seen within the biofilms on 69% (29/42) of the arterial and 88% (23/26) of the central venous catheters. These two direct methods for the detection of biofilm bacteria on the catheter surfaces demonstrated the presence of adherent organisms on 81% of devices examined. Some catheters that had been in place for only 1 day were colonized by bacterial biofilms. Biofilm scraped from catheter surfaces and dispersed by mixing and sonication yielded cultures (32% of catheters) of predominantly skin bacteria. In a few instances, the recovery of bacteria from biofilms on vascular catheters coincided with positive cultures from skin entry site swabs and/or from the blood of the patient, but there was no significant correlation between bacterial recovery from the catheter surface, entry site, and/or patients' blood. CONCLUSIONS: Direct microscopic examination of 68 vascular catheters that had been in place 1 to 14 days showed that most (81%) were colonized by bacteria growing in slime-enclosed biofilms. In many cases, this colonization of catheter surfaces could be confirmed by special biofilm culture recovery methods. Although the clinical importance of bacterial biofilms on catheter surfaces is speculative, their presence and potential to serve as a nidus for infection and bacteremia in critically ill immunocompromised hosts are cause for concern.     

Bipolar Atrial Triggered Pacing to Restore Normal Chronotropic Responsiveness in an Orthotopic Cardiac Transplant Patient

A not uncommon arrhythmia in cardiac orthotopic transplantation patients is sinus node dysfunction with chronotropic incompetence. This is a result of the surgical procedure that denervates the donor heart while the native sinus node may be normal but isolated in the remnant of the recipient atrial wall that serves as the anastomotic site. We were able to restore "normal sinus node function" in a heart transplant patient utilizing a bipolar single chamber pacemaker programmed to the triggered mode. A single unipolar active fixation lead was positioned in each atria. Both leads were connected to a bipolar AAT pulse generator utilizing a Y adaptator. The native atrium with its innervated intact sinus node effectively drove the donor atrium and thus the heart.     

水胶体透明敷料在锁骨下静脉置管导管固定中的应用研究

目的观察应用水胶体透明敷料护理锁骨下静脉置管的效果。方法将153例锁骨下静脉置管的患者按随机数字表分为对照组79例和观察组74例,对照组应用3M HP Tegaderm TM敷料固定导管,观察组用水胶体透明敷料固定导管,比较两组患者置管并发症发生率、非计划性拔管情况和换药总费用及换药工作量。结果观察组置管并发症发生率和非计划性拔管发生率均显著低于对照组;观察组换药频率和换药总时间低于对照组,差异有统计学意义,单次换药时间、换药总费用两组比较无统计学意义。结论水胶体透明敷料能更好地维护锁骨下静脉置管,减少护理工作量。     

胸腔闭式引流中导管固定方法的探讨

目的探讨胸腔闭式引流导管的固定方法。方法按常规方法将中心静脉导管置入胸腔内，将中心静脉导管的固定方法分为A组（贴膜加缝针固定）、B组（贴膜固定）、C组（贴膜固定不缝针加夜间夹管）、D组（贴膜固定加中心静脉导管远端“S”型贴膜固定加棉绳固定）四种，比较四组方法的固定效果。结果A组、B组及C组组间比较差异无显著意义（P〉0．05）；D组与A组比较差异有显著意义（P〈0．05）；D组与B组比较差异有显著意义（P〈0．05）；D组与c组比较差异有显著意义（P〈0．05）。结论D组固定方法固定效果好，操作简单、经济实用、不影响引流效果，值得临床推广应用。     

Delayed Pinpoint Exposure of a Pacemaker Following Seat Belt Trauma

A case of late pinpoint exposure of a pulse generator due to seat belt trauma is reported. This unusual complication indicates that the implant site of a pacemaker should be decided after consideration of where the patient usually sits in his car and what type of seat belt is used.     

Nonsurgical management of cardiac tamponade caused by a temporary pacemaker lead

Right ventricular perforation secondary to temporary pacemaker lead, resulting in cardiac tamponade, is a rare but life-threatening complication. Surgery is usually the definitive management described for such cases. We describe successful sealing of such a perforation by percutaneous instillation of cyanoacrylate glue, through a guiding catheter in the pericardial sac at the perforation site.     

The Recessed Chest Wall Pacemaker Pocket

Recurrent pouch problems led to the development of a recessed chest wall pacemaker pocket. Segments of the seventh and eighth ribs were resected in the mid-axillary line resulting in a "tailor-made" space suitable for generator implantation. Follow-up at one year has proven the chest wall to be a satisfactory alternative site for a pacemaker pocket.     

Successful conservative management with positive end-expiratory pressure for massive haemothorax complicating pacemaker implantation

Haemothorax resulting from injury to a great vessel is a potential complication during transvenous pacemaker implantation that can be caused by perforation by the electrode. If the amount of bleeding is massive, control needs thoracotomy. We report on a 70-year-old man who had a massive haemothorax following transvenous pacemaker implantation. This complication was controlled successfully by using positive end-expiratory pressure (PEEP). We conclude that this simple but reproducible experience may offer effective haemostasis for a massive haemothorax caused by transvenous catheter perforation.     

Demonstration of the Feasibility of Implantation of a Skeletal Muscle Pulse Generator for Fecal Incontinence in a Patient with an Implanted Unipolar DDD Pacemaker

Electromagnetic fields and myopotentials from skeletal muscle may interfere with the function of a cardiac pacemaker. A 65-year-old woman with a unipolar DDD cardiac pacemaker underwent dynamic graciloplasty (transposition of the gracilis muscle around the anal canal and subsequent implantation of a bipolar pulse generator to stimulate the gracilis muscle), for the treatment of fecal incontinence. This gracilis pulse generator is turned "off" with an external magnet to allow defecation. Appropriate functioning of these two pulse generators (the cardiac pacemaker and the gracilis pulse generator) was tested during implantation of the gracilis pulse generator and afterwards. It was demonstrated that the combination could be used safely in this patient.     

Percutaneous permanent pacemaker implantation via the azygous vein in a patient with superior vena cava occlusion

Occlusion of the superior vena cava (SVCO) makes implantation of permanent pacemakers challenging and difficult. We describe an extended application of a Medtronic Attain (Medtronic Inc., Minneapolis, MN, USA) guide catheter (a tool designed for delivery of left ventricular pacing leads into the coronary sinus) for delivery of a right ventricular pacing lead via the azygous vein in a 72-year-old woman with SVCO secondary to long-term central venous hemodialysis catheters. This approach allowed the use of an endocardial pacing lead, implantation under local anesthesia, and conventional positioning of the pacemaker generator in the pectoral region in a patient with SVCO.     

Long-Term Thrombosis after Transvenous Permanent Pacemaker Implantation

To assess the efficacy of prophylactic administration of anticoagulant and antiaggregant drugs to prevent venous thrombosis after long-term transvenous permanent pacemaker implantation, venograms were performed in 100 consecutive patients at the elective replacement of the pacemaker. Mean follow-up period after initial transvenous permanent pacemaker implantation was 6.0 years. The venograms demonstrated normal in 77 patients. The remaining 23 venograms showed venous stenosis in 11 patients and total obstruction in 12 patients. Twenty-one of these 23 patients had venous collateral circulation. No difference was found in the incidence of venous abnormalities according to the route of entry, the lead insulation, the total number of the implanted leads, and anticoagulant and antiaggregant drugs. All these patients have remained asymptomatic. In conclusion, the incidence of venous thrombosis after long-term transvenous pacing is 23% and the causes of venous thrombosis may be endothelial trauma and underlying venous stenosis. As this article describes a retrospective limited study, we cannot find the efficacy of prophylactic administration of anticoagulant and antiaggregant drugs to prevent venous thrombosis formation after transvenous permanent pacemaker implantation. Further prospective study will be needed to assess the efficacy of prophylactic administration of anticoagulant and antiaggregant drugs.     

Tips for monitoring the position of a central venous catheter. How placement can go awry--even when the anatomy is normal

Malpositioning of a central venous catheter can cause potentially life-threatening complications. Knowledge of thoracic anatomy and close attention to proper insertion technique increase the likelihood of, but do not ensure, proper placement. Selection of a right-sided venous entry site reduces the risk of malpositioning. The return of nonpulsatile, dark-colored blood is a strong, but not infallible, indication of venous placement. Do not assume that venous system valves preclude malpositioning. Use chest films to confirm accurate insertion. When these are equivocal, take simultaneous blood samples from a peripheral artery and the central line; the samples will have markedly different blood gas levels if the catheter is in a vein.     

Venous complications after insertion of a transvenous pacemaker.

We reviewed the incidence, clinical features, current diagnostic evaluations, and treatments of venous complications that can occur after implantation of a transvenous pacemaker. Of the approximately 80 published articles on the potential venous complications after implantation of a permanent transvenous pacemaker, we selected 63 that addressed the clinical features, diagnosis, and treatment of pacemaker lead-induced venous thrombosis, which occurs in approximately 30 to 45% of patients early or late after implantation of a transvenous pacemaker. Most patients with chronic deep venous thrombosis remain asymptomatic because of the development of an adequate venous collateral circulation. Clinical features of pacemaker lead-induced deep venous thrombosis, although rare, are easily recognized. They should be sought routinely during follow-up of all patients with transvenous pacemaker leads because venous obstruction can interfere with intravenously administered therapy, monitoring of central venous pressure, and revision of a pacemaker lead. Acute deep venous thrombosis is likely to be symptomatic. Early recognition and treatment of acute deep venous thrombosis may help to decrease the potential morbidity and mortality. The definitive diagnosis of pacemaker lead-induced venous thrombosis necessitates contrast-enhanced or digital subtraction venography. Management includes anticoagulation, thrombolytic therapy, surgical intervention, and, recently, percutaneous transluminal balloon venoplasty and depends on the duration, extent, and site of venous occlusion as well as the accompanying symptoms.     

Recurrent Twiddler's Syndrome in a Nonthoracotomy ICD System Despite a Dacron Pouch

Twiddler's syndrome is a highly recognized yet rare complication of pacemaker and cardioverter defibrillator (ICD) implantation. We present a case in which persistent generator rotation resulted in lead dislodgment and inappropriate shocks in an initial ICD and recurrent lead fracture in a second ICD system. This case is unusual in that even with extensive surgical precautions including use of a Dacron pouch, generator rotation could not be prevented. Submuscular implantation and use of a smaller generator may prevent Twiddler's syndrome.     

Minilaparotomy Salvage of Malfunctioning Catheters in Peritoneal Dialysis

♦ Background: Catheter malfunction is a common and significant complication during peritoneal dialysis (PD). We developed a minilaparotomy procedure to rescue malfunctioning catheters and to prevent recurrence of malfunction.♦ Methods: From 2006 to 2011, 11 patients receiving PD had a malfunctioning catheter. In all patients, a 2-cm incision, 5 cm caudally to the previous peritoneal entry site was used to correct the malfunctioning catheter, with concomitant fixation of the catheter to the peritoneum.♦ Results: Catheter tip migration occurred in 7 patients, omental wrapping in 3, and blood clot obstruction in 1. The mean onset time to catheter malfunction was 197.5 days (range: 4 - 1270 days), and the mean operating time was 41 minutes (range: 35 - 56 minutes). There was no recurrence of catheter malfunction and no surgery-related peritonitis.♦ Conclusions: Our minilaparotomy procedure is safe and feasible for the salvage of malfunctioning PD catheters.Key words: Catheter tip migration, omental wrappingCatheter malfunction, defined as mechanical failure in dialysate inflow or drainage, is not uncommon in peritoneal dialysis (PD) patients. The most common causes of catheter malfunction are catheter tip migration and omental wrapping. Catheter malfunction develops in 3.9% - 13.3% of patients with a Tenckhoff catheter (1,2). Catheter malfunction leads to interruption of PD, and a rescue operation such as fluoroscopy-guided manipulation using correction instruments, or laparoscopy or minilaparotomy is usually required (1-10). The success and malfunction recurrence rates vary between methods because of differences in the procedures.We previously introduced a catheter implantation technique using two-point catheter fixation to straighten the intraperitoneal catheter segment (11). In the present study, we extended that idea to the rescue of malfunctioning catheters and the prevention of recurrent catheter migration and omental wrapping.     

Use of the contralateral subclavian vein for placement of atrial electrodes in chronically VVI paced patients

Two patients with documented pacemaker syndrome were referred for AV sequential pacing and were found to have inaccessible venous systems on the side of their original transvenous pacemaker placement. The contralateral subclavian vein was subsequently catheterized with an atrial electrode using the sheath-set technique. Then the proximal aspect of the atrial endocardial lead was tunneled to the original pacemaker pocket. Once accomplished, both (atrial and ventricular) leads were connected to an AV sequential pulse generator. The united pulse generator and lead were reinserted in the original pacemaker pocket.     

Central venous access device occlusions: part 1: thrombotic causes and treatment

Many home care patients have central venous access devices to administer a variety of infusion therapies. Catheter occlusion is a potential complication. This month, catheter occlusion due to thrombotic causes is addressed. In many cases, thrombotic occlusions can be treated, sparing patients trauma and the expense of replacing the catheter. Thrombolytic drug therapy using the drug alteplase can be performed in the home setting to "declot" central venous access devices. Next month, occlusion due to nonthrombotic causes will be described.