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.     

Mid-systolic click, late systolic murmur syndrome associated with complete heart block.

A 60 year old woman is presented who had the mid-systolic click, late systolic murmur syndrome, documented by phonocardiogram and left ventricular angiography. During an episode of non-anginal chest pain, advanced heart block was demonstrated and permanent transvenous pacemaker therapy was subsequently instituted. The association of the mid-systolic click, late systolic murmur syndrome and heart block is reviewed. It is suggested that 24-hour continuous electrocardiographic monitoring, as well as exercise stress testing, be included in the evaluation of patients with this syndrome.     

Termination of recurrent supraventricular tachycardia by right ventricular endocardial pacing but not by left ventricular epicardial pacing

Externally controlled ventricular pacing was employed in a patient with recurrent disabling supraventricular tachycardia and frequent sinus pauses between attacks of tachyarrhythmia. A permanent transthoracic demand pacemaker was inserted after electrophysiologic study demonstrated the effectiveness of ventricular stimulation in terminating induced supraventricular tachycardia. Subsequently, spontaneous recurrences of tachyarrhythmia failed to respond to fixed rate left ventricular stimulation accomplished by placing a magnet externally over the pacemaker pack. During an induced supraventricular tachycardia, repeat electrophysiologic study demonstrated that paced left ventricular beats failed to invade the A-V junctional area before it was depolarized previously by the corresponding tachycardia beat. Right ventricular stimulation from a transvenous pacemaker could depolarize the site of the reentrant circuit and terminate an induced supraventricular tachycardia. The addition of propranolol increased the ease by which spontaneous attacks of tachyarrhythmia could be terminated by right ventricular endocardial pacing.     

Pacemaker pseudodysfunction with a coronary sinus pacemaker

A permanent transvenous coronary sinus pacemaker functioned effectively for 22 months both as an atrial and ventricular pacemaker. Slow atrial flutter resulted in failure of the pacemaker to capture the myocardium and thus incorrectly suggested pacemaker dysfunction. Transtelephonic evaluation of this phenomenon was particularly difficult and could have resulted in unnecessary replacement of the pacing unit     

External transcutaneous pacemakers in interhospital transport of cardiac patients

From October 1985 to April 1988, 297 patients with presumed unstable angina, acute myocardial infarction, or permanent pacemaker failure were transferred by helicopter from community hospitals to our medical center for tertiary care. Fifty-six patients (19%) experienced treatable bradycardia (heart rate of less than 50) and hypotension (systolic pressure of less than 80 mm Hg); nine patients (16%) improved without treatment, 24 (43%) responded to atropine, and 23 (41%) were unresponsive to atropine. An external transcutaneous pacemaker (EXTP) was applied to patients unresponsive to atropine if a transvenous pacemaker could not be placed. In the atropine-unresponsive group, 11 (48%) had a transvenous pacemaker placed successfully, two (9%) had poor transvenous pacemaker capture (followed by EXTP capture), and ten (43%) were treated with EXTP alone. Eleven patients experienced EXTP capture and improved. Six had profound bradycardia and apnea before EXTP application. Of the 297 patients, 23 (8%) required transvenous or external pacing, and 12 of these patients (52%) survived. The availability of external pacing during interhospital transport of high-risk cardiac patients seems necessary for the management of symptomatic bradycardia and hypotension.     

Severe tricuspid valve stenosis secondary to pacemaker leads presenting as ascites and liver dysfunction: a complex problem requiring a multidisciplinary therapeutic approach

Tricuspid stenosis secondary to ventricular pacemaker leads is uncommon. We present a unique case of iatrogenic tricuspid stenosis secondary to fusion of the valve leaflets to transvenous implanted pacing leads. This occurred in an adult with childhood repaired Tetralogy of Fallot and high grade surgical heart block following multiple pacemaker procedures. The case was complicated by superior vena cava (SVC) and innominate vein stenosis secondary to implanted pacing leads, severe tricuspid valve (TV) stenosis, perforation of the heart by one of the implanted transvenous ventricular pacing leads, prolapse of the transvenous atrial pacing lead into the right ventricle, and unusual coronary sinus anatomy. We describe a multidisciplinary approach to management.     

Early pacemaker lead thrombosis leading to massive pulmonary embolism

Clinically apparent pulmonary embolism is a rare complication of permanent transvenous pacing catheters. Here we report an unusual case of a 71-year-old man who developed massive pulmonary embolism 12 hours after a permanent transvenous pacemaker implantation in the absence of any patient-related predisposing factor. Transesophageal echocardiography showed a large thrombus within the right atrium closely attached to the pacemaker lead. Anticoagulation with heparin, followed by warfarin therapy, led to a complete resolution of the thrombus.     

Safe right bundle branch block pattern during permanent right ventricular pacing

It is known that an electrocardiogram (ECG) after transvenous right ventricular (RV) pacing should yield left bundle branch block (LBBB) QRS patterns. When right bundle branch block (RBBB) pacing morphology appears in a patient with a permanent or temporary transvenous RV pacemaker, myocardial perforation or malposition of the pacing lead must be ruled out, even though the patient may be asymptomatic. We report a case of a 77-year-old man who underwent permanent transvenous VDD pacemaker implantation for symptomatic heart block. The postoperative ECG revealed a RBBB pacing configuration, but his chest X-ray and echocardiographic studies confirmed uncomplicated RV pacing. We review and discuss the literature concerning the differential diagnosis of such a safe RBBB ECG pattern.     

床边插管法在临时心脏起搏的应用

目的 :探讨在起搏脉冲发生器起搏与感知的指导下 ,结合心脏听诊定位进行临时心脏起搏的可行性。方法 :应用深静脉穿刺和带漂浮球囊的起搏电极 ,在起搏脉冲发生器起搏与感知的指导下结合心脏听诊定位 ,进行床旁临时心脏起搏。结果 :72例起搏均获成功 ,且均无严重心律失常发生。结论 :床旁临时心脏起搏无X光显示盲目插管法在起搏脉冲发生器起搏与感知的指导下结合心脏听诊定位是安全有效的     

Pacemaker-induced cardiovascular failure. Hemodynamic and angiographic observations

A 71 year old woman underwent permanent transvenous right ventricular pacemaker implantation for prolonged syncope and atrioventricular conduction defects. Each time the patient's heart rate spontaneously decreased to less than 70 beats/min, cardiovascular collapse with hypotension and reduced cardiac output occurred. Left ventricular cineangiography performed during both sinus rhythm and right ventricular pacing demonstrated reduced left ventricular end-diastolic volume, secondary to a loss of atrial contribution to left ventricular filling, and severe, acute mitral regurgitation with significantly decreased effective stroke volume and cardiac output. Pacing from the left ventricular endocardium had the same effect. The detrimental effects of cardiac pacing necessitated removal of the right ventricular pacemaker.     

Probable postcardiotomy syndrome following implantation of a transvenous pacemaker: report of the first case.

The syndrome of fever and pericarditis is reported following implantation of a transvenous pacemaker in a 72-year-old man. The pacemaker was placed for prophylactic reasons (i.e., presence of bifascicular block). The syndrome resolved spontaneously after over four weeks of fever and a pericardial friction rub. Perforation of the right ventricle, although not recognized in this patient, is a complication which occurs with passage of a transvenous pacemaker. There was no other antecedent events to explain the syndrome such as myocardial infarction or trauma to the chest.     

Late systolic murmur of rheumatic mitral insufficiency

Of 184 patients with acute rheumatic fever and associated mitral insufficiency encountered during a 15 year period, 34 manifested a mid-late systolic murmur or a nonejection click, or both, during the course of follow-up.The mid-late systolic murmur later disappeared in four patients whose condition is now considered normal. In one of the four, systolic prolapse of the mitral valve was demonstrated on an angiocardiogram obtained when the systolic murmur was present. Since disappearance of the murmur there has been no evidence of systolic prolapse on meticulous echocardiographic study of the mitral valve. In another child with angiographically demonstrated systolic prolapse of the mitral valve the systolic murmur has also disappeared, but systolic prolapse is still evident on echocardiographic study.None of the 34 patients with a mid-late systolic murmur manifested the T wave abnormalities commonly associated with the familial variety of mitral valve prolapse.     

Temporary coronary guidewire pacing during percutaneous coronary intervention.

Temporary pacing is occasionally required during percutaneous coronary artery interventions. This can be accomplished by the insertion of a temporary transvenous pacemaker wire into the right ventricle, but there is some risk and inconvenience associated with this approach. Temporary pacing using the coronary artery guidewire was described in 1985 but is used infrequently. Using currently available equipment, we evaluated guidewire pacing in 26 patients. Guidewire pacing was successful in all patients, but not with all coronary guidewires at acceptable ventricular capture thresholds. No complications occurred from guidewire pacing. Bench testing of multiple different wires showed several with very high resistances likely unsuitable for clinical use. Temporary guidewire pacing is easily performed and should be considered as an alternative to the separate placement of a temporary transvenous pacemaker.     

External cardiac pacing in right ventricular infarction

A patient with acute inferior wall myocardial infarction presented with clinical evidence of right ventricular infarction complicated by bradycardia and cardiogenic shock. Pharmacologic interventions produced no change in heart rate or blood pressure, and a transvenous pacemaker failed to capture the infarcting right ventricle. An external transthoracic pacemaker immediately increased the heart rate with a marked hemodynamic improvement. In the setting of right ventricular infarction, external pacing may be more effective than transvenous pacing, perhaps due to its ability to pace the left ventricle.     

Chronic cor pulmonale: a rare complication of undiagnosed pacemaker lead endocarditis

Pacemaker lead infection is a rare life-threatening complication of permanent transvenous pacing. We describe the case of a young man who suffered recurrent undiagnosed septic pulmonary embolisms from pacemaker lead vegetations inducing chronic cor pulmonale with major pulmonary arterial hypertension. The potential complications of transvenous pacing and the systematic use of transesophageal echocardiography are emphasized.     

Severe tricuspid regurgitation secondary to dislodgement of the atrial loop into the right ventricle: an unusual complication of pacemaker implantation in a young adult

Transvenous pacemaker leads may impair tricuspid valve function. Severe tricuspid regurgitation due to leaflet adhesion to the pacemaker lead has not been reported in a young adult patient in the literature. Our patient underwent a transvenous pacemaker implantation for symptoms of bradycardia. An atrial loop was created in the right atrium for future growth. After 10 years of follow-up, the patient was seen with severe tricuspid regurgitation and enlarged right heart structures due to migration of the atrial loop of the pacemaker lead into the right ventricle and adhesion of the lead to the tricuspid valve. Cardiac surgery and epicardial pacing was the chosen procedure to solve this problem. The venous system and right heart valves should be carefully observed during the follow-up of children who underwent transvenous pacing.     

Origin of the basal systolic murmurs in mitral stenosis. A study with intracardiac phonocardiography

In order to study the origin of the basal systolic murmurs in mitral stenosis, left and right heart catheterization was performed in 18 patients with mitral stenosis using intracardiac phonocardiography. Our data revealed that the basal systolic murmurs originated in the aorta, the pulmonary artery, and the outflow tract of the right ventricle.In 14 cases, we noted the maximal ejection systolic murmur in the aorta near the aortic valve. However, in two cases, there was a loud systolic murmur in the pulmonary artery. These murmurs occurred in early to mid-systole and were crescendo-decrescendo in configuration. The pitch of the murmur ranged from low to medium frequency in the majority of cases. They are produced by the turbulence of blood flow in the aorta and the pulmonary artery.A late systolic murmur was also recorded in the outflow tract of the right ventricle in two patients. This is thought to occur due to functional or relative infundibular stenosis of the right ventricle. It differs in location and timing from those in the aorta and the pulmonary artery. The outflow tract of the right ventricle is regarded as the third origin of the basal systolic murmur in mitral stenosis.     

Echocardiographic Localization of an Inadvertently Placed Pacing Catheter in the Left Ventricle

This report describes a patient in whom a permanent transvenous pacemaker lead was placed unintentionally across the atrial septum and retained in the left ventricle for nearly 11 years before the error was recognized. A 12-lead electrocardiogram showed paced complexes with right bundle branch block configuration. This appearance raised suspicion that the pacemaker electrode might be in the left ventricle and this was confirmed by two-dimensional echocardiography. Two-dimensional echocardiography is useful for the diagnosis of pacing lead malplacement and should be performed in any patient who develops right bundle branch block pattern on the surface electrocardiogram following pacemaker implantation.     

Streptokinase dissolution of a right atrial thrombus associated with a temporary pacemaker

Thrombosis of intravascular catheters is a well-recognized and potentially serious complication, which has been treated successfully with thrombolytic agents. A routine echocardiogram in a patient with a temporary transvenous pacemaker demonstrated a large thrombus attached to the pacing electrode. This was dissolved successfully and uneventfully with high-dose intravenous streptokinase therapy. To our knowledge, this is the first report of the successful lysis of a right atrial thrombus complicating a temporary transvenous pacemaker.