Facial Swelling: A Complication of Transvenous Pacing

Summary: A case of progressive venous thrombosis involving the superior vena cava is reported following implantation of a permanent transvenous pacemaker. Acute symptoms in the arm appeared after 18 months, but the symptoms of superior vena caval obstruction developed gradually, three years after pacemaker insertion. The diagnosis was confirmed by cavography and symptoms resolved with heparin therapy. Long-term anticoagulation is indicated when thrombosis is responsible for this uncommon but important complication of transvenous pacing.     

心脏起搏治疗小儿缓慢性心律失常30例的经验

目的总结永久性心脏起搏器治疗小儿缓慢性心律失常的经验。方法因症状性缓慢性心律失常在我院住院置入永久心脏起搏器的患儿30例,男19例、女11例,年龄6.8±4.1(1/12~15)岁。>10 kg的患儿全麻下穿刺左锁骨下静脉,放置心内膜起搏电极,起搏器置于左锁骨下皮下脂肪与肌肉间囊袋中;<10kg的婴儿放置心外膜电极,起搏器置于腹部固定于腹直肌。依据不同年龄将起搏频率设置为70~100次/m in(VVI/AAI/DDD),或60~70/130~140次/m in(VVIR/AAIR)。结果所有患儿均成功置入起搏器,无手术并发症发生,其中VVI 19例、VVIR 7例、AAI 2例、AAIR 1例、DDD 1例;经左锁骨下静脉放置心内膜电极27例,经腹部置入心外膜电极3例。术后随访3个月~6年,患儿体力均有明显改善,异常的左室内径和左室射血分数均于术后3个月内恢复正常。结论小儿起搏器治疗有效、安全,应根据患儿体重及全身状况选择适宜的起搏系统。     

Treatment of refractory recurrent multifocal atrial tachycardia with atrioventricular junction ablation and permanent pacing

Multifocal atrial tachycardia is a difficult clinical problem generally associated with acute cardiorespiratory illness. The purpose of this study was to assess the feasibility and clinical utility of atrioventricular junction ablation plus permanent transvenous pacemaker implantation as therapy for uncontrolled refractory multifocal atrial tachycardia. Three patients with uncontrolled refractory multifocal atrial tachycardia underwent atrioventricular junction ablation plus permanent transvenous pacemaker implantation. Complications and outcome of each procedure was monitored and both objective and subjective assessment of physical functional capacity was assessed by a semiquantitative examination. Ablation procedures controlled the ventricular response in all patients. There were no complications related to the ablation procedure or implantation of permanent transvenous pacing system. All patients demonstrated subjective improvement in symptoms. Palpitations were virtually eradicated in these patients and all enjoyed significant improvements in rest and effort dyspnea, exercise tolerance and asthenia. Objective assessment of functional class also demonstrated significant improvements. Atrioventricular ablation plus permanent transvenous pacing offers a safe and effective therapy for uncontrolled refractory multifocal atrial tachycardia.     

Permanent cardiac pacing using anterior pectoral veins.

We have used the anterior pectoral veins for inserting permanent transvenous cardiac pacemaker electrodes in 260 patients. Though this route is used in other centres it has not been published. We found it to be a reliable alternative to the more usual routes of pacemaker insertion, with a combined perforation and displacement rate of 9.6 per cent. We describe this technique of electrode insertion and compare the complication rates with those of other routes of implantation used in our department. All of the pacemaker implantations in this study were performed by doctors in the cardiology department, with no specialist surgical training.     

Pacemaker catheter induced systolic murmurs in two patients

Although extracardiac sounds secondary to cardiac pacing have been well known, the murmurs originating in the heart after permanent pacemaker implantation and then disappearance after exchanging a temporary to permanent lead have rarely been reported. In this paper, two patients revealing a musical systolic murmur after placement of a transvenous endocardial pacemaker in the absence of any complications were documented. Case 1: A 43-year-old man with episodes of dizziness and brady-tachycardiac atrial fibrillation. Immediately after the implantation of a temporary transvenous right ventricular pacemaker, a high-pitched systolic musical murmur was heard at the lower left sternal border. No murmur was however gullible after a permanent pacemaker implantation in this case. Case 2 was a 83-year-old female with coronary heart disease associated with sick sinus syndrome to whom a permanent transvenous right ventricular pacemaker was inserted. A musical systolic murmur occurring immediately after the procedure was best audible at the apex. Although numerous papers concerning the mechanisms of these cardiac murmurs have been reported without reaching conclusive explanations, our data based on two cases examined with Doppler echocardiography did not support the idea of tricuspid regurgitation as one of causative factors. In the first case, this murmur appeared only a temporary pacing was performed and disappeared after implantation of a permanent pacemaker lead. On the contrary, however, the 2nd case revealed after the implantation of the permanent pacemaker with a relatively rigid bipolar lead. It is concluded that these murmurs might be produced by vibrations caused by the pacing catheters and physical properties could be related the mechanism of this phenomenon.     

Venogram-guided extrathoracic subclavian vein puncture

BACKGROUND: Subclavian vein puncture is commonly performed to insert the pacing lead for permanent pacemaker implantation. Our aim was to study the safety and feasibility of venogram-guided extrathoracic subclavian vein puncture for permanent pacemaker lead insertion. METHODS AND RESULTS: Sixty patients (32 males, and 28 females) underwent permanent pacemaker lead insertion by extrathoracic subclavian vein puncture at our institute between March 2002 and December 2002. Fifteen patients underwent dual-chamber and 45 single-chamber pacemaker implantation. All the patients underwent extrathoracic subclavian vein puncture guided by venogram, except 1 who underwent dual-chamber pacemaker implantation in whom the ventricular lead insertion was via the cephalic vein on an elective basis. The procedure was successful in all the patients. Inadvertent subclavian artery puncture occurred in 2 patients without any complication. There was no incidence of pneumothorax, hemothorax or pacemaker site infection. CONCLUSIONS: Venogram-guided extrathoracic subclavian vein puncture is safe and successful. It may be adopted as one of the preferred approaches for permanent pacemaker lead insertion.     

Biventricular implantable cardioverter defibrillator use in a patient with heart failure and ventricular tachycardia secondary to Emery-Dreifuss syndrome.

We report a case of fully transvenous single-unit biventricular implantable cardioverter defibrillator (ICD) use in a 43-year-old woman with a manifesting carrier form of muscular dystrophy (Emery-Dreifuss syndrome). The indication for biventricular ICD use was progressive heart failure with ventricular arrhythmia, permanent atrial fibrillation and previous VVIR pacemaker insertion. Single-unit transvenous biventricular ICD implantation was undertaken without complication. No potentially serious device malfunction was noted during subsequent follow-up. We conclude that single-unit biventricular ICD implantation is feasible for pacing and ventricular tachyarrhythmia control in patients with underlying atrial fibrillation.     

Repeated postpericardiotomy syndrome following a temporary transvenous pacemaker insertion, a permanent transvenous pacemaker insertion and surgical pericardiotomy

The postpericardiotomy syndrome is a well-known complication of opening and manipulating the pericardium. The occurrence of this syndrome following transvenous pacemaker insertion is very rare, and only 5 cases have been reported to date. The present patient repeated this syndrome 3 times in a short period following 3 different interventional techniques: a temporary transvenous pacemaker, a permanent transvenous pacemaker and surgical pericardiotomy.     

Digital subtraction venography for assessment of deep venous thrombosis in the arms following pacemaker implantation

We recently performed digital subtraction venography and detected axillary venous thrombosis in a 56-year-old female with nonspecific symptoms related to the right arm following a permanent transvenous endocardial pacemaker implantation two years ago. In view of its cost-effectiveness and less invasive approach, digital venography appears ideally suited for evaluation of the frequently occurring subclinical deep venous thrombosis in these patients.     

Juvenile tricuspid stenosis and rheumatic tricuspid valve disease: an echocardiographic study

It has been suggested that the incidence of thromboembolic events always increases in patients after insertion of a transvenous pacemaker. Blood samples from twenty consecutive patients (fifteen males and five females) before and after pacemaker implantation was retained for platelet aggregability studies which were analyzed separately with ADP, collagen, epinephrine and arachidonic acid. The maximal amplitude of platelet aggregatory curve was detected by an aggregometer. The samples collected the day before pacemaker implantation (day 0) were used as self-control. Day 1 and day 3 after pacemaker implantation were defined as the acute phase, while day 30 was defined as the chronic phase. The maximal amplitude of platelet aggregatory curve was observed to be lowest on day 1 and then return to normal on day 3 and day 30. The results of platelet aggregability, however, showed no significant difference (P>0.05) between self-control and post-implantation samples. In conclusion, there was no significant change in platelet aggregability for either acute or chronic phases after pacemaker implantation. Antiplatelet medications may not be necessary for the prevention of thromboembolic events after the implantation of a pacemaker.     

Permanent Pacemaker Lead Insertion Connected to an External Pacemaker Generator for Temporary Pacing After Transcatheter Aortic Valve Implantation

BackgroundOutcomes after transcatheter aortic valve implantation (TAVI) have been demonstrated to be at least equivalent in the short term compared to surgical valve implantation (SAVI). However, Conduction abnormalities are more common after TAVI than SAVI and the need for permanent pacemaker implantation is more common after TAVI with the currently commercially available self-expanding valves than after SAVI. Temporary pacemaker implantation may be associated with inability to ambulate, lead migration or perforation and infection. Depending on the monitoring system, some arrhythmias may not be detected. We examined the feasibility and safety of permanent pacemaker lead implantation connected to an external generator in patients undergoing TAVI at our institution.MethodsThis is a retrospective analysis of consecutive patients (between April 1st 2014 and April 30th 2016) at a single center without permanent pacemaker at the time of TAVI who underwent implantation of a permanent pacemaker lead after TAVI connected to an external generator. Focus was the examination of feasibility and safety of our aforementioned approach. In addition, data analysis was performed separating patients into two groups depending on whether (group 1) or not (group 2) permanent pacemaker implantation was ultimately needed.ResultsPer our institutional protocol, all consecutive 114 patients underwent insertion of a permanent pacemaker lead after TAVI connected to an external generator. There was one pericardial effusion on postoperative day one that may have been related to the left ventricular wire for TAVI valve delivery. However, perforation due to the pacemaker lead cannot be excluded. Specifically, no access site complications, lead dislodgments or infections occurred. All patients were able to ambulate after the procedure without delay. The permanent pacemaker lead remained in place on average for 4.3 days in group 1 (n = 10) and 4.4 days in group 2 (n = 104) (variance of 3.8 and 3.4 days respectively, [minimum/maximum 0/11 days and 1 and 12 days]). Of the ten patients (9%) who required permanent pacemaker implantation, 8 had a complete atrioventricular block and two had tachy-brady arrhythmias in the context of atrial fibrillation. None of the baseline characteristics including baseline conduction abnormalities were predictors for PPI.ConclusionImplantation of a permanent pacemaker lead connected to an external generator is feasible and safe and could be a better option than implantation of a temporary lead connected to an external generator. It may allow earlier ambulation and facilitate monitoring.     

Defibrillation testing and early neurologic outcome

During implantable cardioverter-defibrillator (ICD) implantation, ventricular defibrillation testing (DFT) is considered a standard procedure. This procedure often requires multiple ventricular fibrillation (VF) inductions. These repeated short episodes of circulatory arrest with global cerebral ischemia may cause neurological damage. In the present study, patients undergoing initial ICD implantation and limited induction of VF for defibrillation safety margin testing were evaluated for pre- and postoperative cognitive and neurologic functions. In addition, the serum neuron specific enolase (NSE) level, which is a biochemical marker of cerebral injury, was evaluated. The study was performed on 16 patients undergoing initial elective transvenous insertion of an ICD. A neurologic examination and cognitive assessment tests were performed 24 to 48 hours before and after ICD. NSE was determined before (NSE 1) and at the end of the surgery (NSE 2), as well as 2 hours (NSE 3), 24 hours (NSE 4), and 48 hours (NSE 5) after implantation. A total of 29 internal shocks (average, 1.8 +/- 0.4) with energy ranging from 14 to 41 J (mean, 20 +/- 5; median, 20 J ) were delivered in the ICD group patients. In one patient, 3 external (50, 200 and 360 J) shocks were required for fast VT induced during ICD lead positioning. The mean duration of VF was 10 +/- 4 seconds and the mean cumulative time in VF was 16 +/- 5 seconds. The mean recovery time between VFs was 5.3 +/- 0.6 minutes. NSE levels were not different from the baseline at any time point in the patients of the group that completed the 48-hour observation period (P > 0.05). The patients did not report any new neurological symptoms after ICD implantation, and repeat examination after the procedure showed no abnormal findings other than those detected in the previous one. There were no statistically significant differences between the preoperative and postoperative scores obtained in the cognitive assessment. Single or two VF inductions and the brief arrest of cerebral circulation during ICD implantation are not associated with permanent neurological injury. However, further studies are needed to confirm this finding.     

Percutaneous treatment of superior vena cava obstruction following transvenous device implantation.

The aim of this study is to assess the feasibility and safety of percutaneous treatment of superior vena cava (SVC) obstruction following transvenous device implantation. SVC obstruction is an uncommon but serious complication that can occur following permanent pacemaker or cardioverter defibrillator implantation utilizing transvenous endocardial leads. The treatment has traditionally been surgical but with the advent of stents, percutaneous approach is becoming popular. We report on the prevalence of SVC obstruction and the safety of its percutaneous catheter-based treatment. This is a retrospective study of SVC obstruction following device implantation in our institution from January 1993 through November 2003. A total of 1,850 permanent pacemaker and 1,200 implantable cardioverter defibrillator initial implants were performed during that period. Three patients developed SVC obstruction following implant (prevalence, 1/1,000 implant). Two patients were males and the mean age at implant was 57 +/- 13 years. Laser lead extraction and SVC angioplasty with or without stenting were performed in all patients. In two of them, this was followed by reimplantation of new systems. There were no procedural complications or mortality. The patients remain free of SVC obstruction symptoms 24 +/- 19 months after treatment. SVC obstruction prevalence after device implantation is low. Percutaneous treatment of SVC obstruction can be safely performed and appears to be effective in maintaining medium-term patency.     

Significance of prolonged electrocardiographic pauses in sinoatrial disease: sick sinus syndrome

Eighty-four patients (2.6%) were found to have prolonged (≥ 2.0 seconds) sinoatrial pauses in a review of 3,259 consecutive patients who had 24-hour Holter electrocardiographic studies. Pauses averaged 2.6 ± 1.5 seconds (± standard deviation) (range 2.0–15.2). In 17 (20%), no underlying heart disease was found and in 8 (10%), prolonged pauses appeared to be drug-induced. No relation was found between length of pauses and presence of symptoms or risk of death. Twenty patients received a pacemaker. Pacemaker recipients were older and more likely to be male and to have symptoms, although 7 were asymptomatic. Patients who received a permanent pacemaker were not different from nonrecipients with respect to average longest pause, mechanisms of pause, underlying heart condition or average time of follow-up. However, the survival rate was not improved by permanent pacemaker implantation. Of the 17 patients who died, only 3 died of cardiac causes; none had a recognizable bradycardic cause. Thirteen who initially had syncope did not receive a pacemaker; 2 died of noncardiac causes and none had a subsequent syncopal episode. Ten patients with a syncopal episode received a permanent pacemaker; 3 subsequently died and 3 survivors continued to complain of dizziness. Of the 37 patients who did not have any symptoms on initial examination, only one subsequently had a syncopal episode. Thus, length of sinoatrial pauses correlates poorly with symptoms and does not predict sudden death. Unless prolonged sinoatrial pauses are shown to cause symptoms, such pauses per se are not an indication for permanent pacemaker implantation.     

Right ventricular failure due to postpericardiotomy syndrome following transvenous dual chamber permanent pacemaker implantation

"Pericardial effusion and tamponade are recognised complications of permanent transvenous pacemakers implantation. This is more common when active fixation leads are used. We describe a patient who developed right ventricular failure with significant pericardial effusion following permanent transvenous pacemaker implantation."     

Trastornos graves de la conducción cardiaca e implante de marcapasos en pacientes con miocardiopatía hipertrófica

The aims of this study were to determine the prevalence of severe cardiac conduction disturbances in a cohort of 451 patients with hypertrophic cardiomyopathy and to describe the characteristics of, and outcomes in, those who required a permanent pacemaker. A pacemaker was implanted in 48 patients (11%): 20 had sinus node dysfunction and 28 had an atrioventricular conduction disturbance. Primary bradyarrhythmia (which was not related to iatrogenic atrioventricular block or therapeutic ablation of the atrioventricular node) was the reason for permanent pacemaker implantation in 36 patients (8%). In 18% of cases, at least one other family member had a permanent pacemaker. In this patient series, a high prevalence of severe cardiac conduction disturbance leading to permanent pacemaker implantation was observed. Severe cardiac conduction disturbance in hypertrophic cardiomyopathy may also have a familial component.     

Pacemaker related endocarditis: analysis of seven cases

Vegetative electrode infection following permanent pacemaker implantation is a rare and serious complication. Among 1920 patients who underwent permanent pacemaker implantation in our institute between 1980 and 2000, 7 patients aged 65 to 78 years were diagnosed to have pacemaker related endocarditis. In this study, the clinical course and management strategies for these patients are reviewed. The most frequently encountered factors contributing to development of pacemaker infection were local complications such as postoperative hematoma and inflammation, and recurrent surgical interventions on the pacemaker system. In blood cultures S. aureus was the most common causative microorganism. Echocardiography could be performed in 5 patients. Three patients were referred to open-heart surgery for total removal of the pacemaker system, and one patient had his pacemaker system removed percutaneously. The remaining 3 patients did not agree to either surgical or percutaneous removal. These patients have been under antibiotic therapy for approximately 3 years and they still do not have any signs of a serious infection. Consequently, in patients with permanent pacemakers, infective endocarditis should be considered in the presence of fever and local symptoms. Blood cultures should be obtained and echocardiography should be performed. Complete removal of the pacemaker system with intensive antibiotic treatment is necessary for complete eradication of the infection. However, if percutaneous or surgical removal of the electrodes cannot be done because of high perioperative risk or the patient does not agree to undergo either method, medical treatment with long term antibiotic use may be considered as an alternative.     

Superior vena cava syndrome as a complication of transvenous permanent pacemaker implantation

Venous thrombosis induced by a transvenous permanent pacemaker is a common complication. However, superior vena cava (SVC) syndrome caused by pacemaker leads is only occasionally seen and its prevalence has been estimated to be less than 1 in 1000 pacemaker patients. Herein, we report a Taiwanese patient of high grade AV block, who presented with SVC syndrome 2 years after transvenous permanent pacemaker implantation. This case features fibrotic stenosis of the junction of right brachiocephalic trunk and SVC, and an extensive thrombus formation resulting in complete obliteration of the left brachiocephalic vein. The collateral circulation was so delicate that he still could lead a rather normal life, even if anticoagulant therapy proved to be ineffective from an angiographic point of view.     

Predictors of permanent pacemaker implantation during the early postoperative period after valve surgery

The ability to preoperatively identify patients who may require permanent pacemaker implantation is rather poorly understood. The aim of this study is to determine the current incidence of permanent pacing after valve surgery and to determine which factors place the heart valve patient at risk of requiring permanent pacemaker implantation. We audited the records of 2,392 consecutive adult patients who underwent cardiac valve surgical procedures by the same surgical team from 25 April 1998 through 31 March 2003. Of these, 118 patients (group A) required the postoperative implantation of permanent pacemakers during the same hospitalization; they were compared with 1,959 heart valve patients (group B) who did not require pacemaker placement. Multivariate logistic regression analysis showed that reoperations (odds ratio [OR], 8.23; P <0.001), longer cumulative cross-clamp times (OR, 5.9; P <0.001), multiple-valve surgical procedures (OR, 3.46; P <0.05), and absence of preoperative sinus rhythm (OR 2.52; P <0.001) were independent predictors of the need for permanent pacemaker implantation after valve surgery. These results suggest that patients who display these risk factors for arrhythmias that require permanent pacemaker implantation receive closer observation and advance counseling about the likelihood of such implantation.     

Long-term follow-up after cardiac pacing in bradyarrhythmias

Fifty-nine patients aged 39-80 years underwent implantation of a cardiac pacemaker and were followed for up to 9 years (average duration of pacing 39 months). Atrioventricular conduction disturbances (complete atrioventricular block, 2 : 1 atrioventricular block, bifascicular block, and atrial fibrillation with slow ventricular rate) were present in 49 patients and sick sinus syndrome (sinus arrest or sino-atrial block, and bradycardia-tachycardia syndrome) in 10. Pacing was required because of Adams-Stokes attacks in 41 patients, 2 of whom also had congestive heart failure. It was required in 6 because of frequent dizziness, in 10 because of congestive heart failure, and in 2 because of low cardiac output. The symptomatic improvement after cardiac pacing was well recognized in most of our patients, and 32 (54 percent) of the 59 patients pursued normal physical and daily activity. Although the efficacy of pacemaker therapy was of limited value in some patients with congestive heart failure or underlying or coexisting diseases, the beneficial effects following pacemaker implantation were: (1) abolishment of transient neurologic symptoms such as Adams-Stokes attack, (2) relief from a constant fear of a recurrence of an Adams-Stokes attack or sudden cardiac death, and (3) improvement in restricted physical activity due to low cardiac output. Thus, we conclude that pacemaker implantation in most patients with bradyarrhythmias is beneficial not only for the treatment of the acute problem but also because it prolongs life and greatly enhances its quality. However, in spite of the beneficial effects after pacemaker implantation, we still observe a number of complications connected with the use of a permanent pacemaker. Therefore, our policy is to implant a permanent pacemaker following the execution of sufficient studies of the bradyarrhythmia and the etiology of symptoms, and then under taking long-term follow-up of the patients.