Implantation of Dual Chamber Pacemaker in a Patient with Persistent Left Superior Vena Cava

A 35-year-old patient underwent permanent pacemaker implantation because of symptomatic sinus bradycardia. During the procedure, persistent left superior vena cava was found. The ventricular lead crossed the tricuspid valve only after curving the stylet to form a loop in the right atrium (RA); subsequently, the curved stylet was changed to a straight one and the lead was positioned and screwed into the right ventricular apex. The atrial lead positioning was possible when the stylet was slightly curved and the lead could reach the anterior wall of the RA. At 18 months, a follow-up revealed normal pacemaker function and stable lead position.     

Postpacemaker implant pericarditis: incidence and outcomes with active-fixation leads

Pericarditis has been noted as a potential complication of pacemaker implantation. This study evaluated the risk of developing pericarditis following pacemaker implantation with active-fixation atrial leads. Included were 1,021 consecutive patients (mean age 73.4+/-0.4 years, range 16-101 years; 45.2% women) undergoing new pacemaker system implantation between 1991 and 1999 who were reviewed for the complication of pericarditis. The incidence and outcomes of postimplantation pericarditis in patients receiving active-fixation atrial leads were compared to those not receiving these leads. Of 79 patients who received active-fixation atrial leads, 4 (5%) developed pericarditis postpacemaker implantation. Of 942 patients with passive-fixation atrial leads or no atrial lead (i.e., a ventricular lead only), none developed pericarditis postoperatively (P < 0.001). Of patients receiving active-fixation ventricular leads only (n = 97), none developed pericarditis. No complications were apparent at the time of implantation in patients who developed pericarditis. Pleuritic chest pain developed between 1 and 28 hours postoperatively. Three patients had pericardial rubs without clinical or echocardiographic evidence of tamponade. They were treated conservatively with acetylsalicylic acid or ibuprofen and their symptoms resolved without sequelae in 1-8 days. One patient (without pericardial rub) died due to cardiac tamponade on postoperative day 6. Postmortem examination revealed hemorrhagic pericarditis with no gross evidence of lead perforation. Pericarditis complicates pacemaker implantation in significantly more patients who receive active-fixation atrial leads. It may be precipitated byperforation of the atrial lead screw through the thin atrial wall. Patients developing postoperative pericarditis should befollowed closely due to the risk of cardiac tamponade.     

Cardiac tamponade as complication of active-fixation atrial lead perforations: proposed mechanism and management algorithm

BACKGROUND: Cardiac tamponade is a rare complication after implantation of dual chamber pacemaker or defibrillator systems. Its pathophysiology and optimal management are not currently well established. METHODS: Three cases of cardiac tamponade following successful implantation of transvenous dual chamber pacemakers with active-fixation atrial leads were identified. RESULTS: All three patients with post-implant cardiac tamponade were suspected to have the same etiology of bleeding into the pericardial space. This was due to protrusion of the helix of the active-fixation atrial pacing lead through the atrial wall with subsequent abrasion of visceral pericardial layer and bleeding from the atrium through the perforation. In two patients, the perforation sites were visualized and repaired during open thoracotomy in the operating room. The third patient underwent lead repositioning under fluoroscopic guidance in the electrophysiology laboratory. CONCLUSION: Based on the reviewed cases, we describe the pathophysiology of, and recommend a safe conservative algorithm for, the management of cardiac tamponade after successful transvenous lead implantation. Percutaneous pericardiocentesis with placement of the pericardial drain followed by lead repositioning under fluoroscopic guidance with surgical backup appears to be safe and effective.     

Delayed right ventricular lead perforation by a pacemaker lead 2‐year post‐implantation

Cardiac perforation by the lead of cardiac implantable electronic devices is a critical complication that often occurs within 24 h after the implantation but can occur later. We report a case of cardiac perforation of the right ventricular wall during the chronic period, 2 years after pacemaker implantation.     

Cardiac stimulation caused by biogalvanic current during pacemaker implantation

After lead positioning during implantation of a biventricular pacing system intermittent ventricular simulation was observed. There was no pacemaker connected to any of the leads, but ventricular capture could be provoked by an intermittent contact between the lead stylet, which was still partially inserted, and a self-retaining retractor. The same phenomenon was observed from the atrial lead.     

Delayed complications following pacemaker implantation

Acute complications resulting from permanent pacemaker implantation are well known and include perforation of the right atrium or right ventricle. Recently, several reports have described the occurrence of perforation and pericarditis as late complications following pacemaker implantation. These complications may occur days to weeks following uncomplicated pacemaker implantation and may lead to death if they are not recognized early. Five patients with late complications caused by active-fixation leads are reported and the clinical features of their presentation and management are reviewed. Late perforation of the right atrium or right ventricle is an uncommon complication after pacemaker implantation but should be suspected by the general cardiologist in a patient who has a device implanted within a week to several months prior to the development of chest pain.     

Guidance of cardiac pacemaker leads using real time 3D ultrasound: feasibility studies

We investigated the feasibility of the guidance of pacemaker lead implantation using the pacemaker lead stylet as an acoustic wave-guide combined with real time 3D ultrasound imaging. In one approach, with a 2.5 MHz transducer coupled to a stylet of a pacemaker lead, we used the stylet as a transmitter to track the vibrating tip in a 3D ultrasound scan. In another approach, we connected the stylet to a piezoelectric actuator vibrating in the range 0.5-5 kHz so that the tip of the stylet was imaged using the color Doppler feature of the real time 3D ultrasound scanner. In both approaches, tracking of the isolated stylet showed good accuracy. However, neither approach offered sufficient signal-to-noise ratio to detect the vibration within the lumen of an intact pacemaker lead.     

Lead Explantation Late After Atrial Perforation

This report describes the case of a patient in whom atrial perforation with penetration of the thoracic wall was diagnosed 2 years after the implantation of an Accufix lead. Despite this complication, atrial detection in the bipolar mode and ventricular pacing were normal. Digital fluoroscopy detected a fracture with extrusion of a short segment of the retention wire. The rupture of the retention wire might have been the result, but was not the cause of the perforation.     

Long-term complication rates in ventricular, single lead VDD, and dual chamber pacing

A higher incidence of pacemaker related complications has been reported in DDD systems as compared to VVI devices. The implantation of single lead VDD pacemakers might reduce the complication rate of physiological pacing in patients with AV block. In a retrospective study, the data records of 1,214 consecutive patients with pacemaker implantation for AV block between 1990 and 2001 (VVI 36.5%, DDD 32.9%, VDD 30.6%) were analyzed. Complications requiring surgical interventions were compared during a follow-up period of 64 +/- 31 months. Operation and fluoroscopic times were longer in DDD pacemaker implantation compared to VDD and VVI devices:58 +/- 23 versus 39 +/- 10 and 37 +/- 13 minutes (P<0.001), 9.2 +/- 5.2 versus 4.1 +/- 2.4 and 3.5 +/- 2.3 minutes, respectively. Differences remained significant after correction for covariates. In a multivariate Cox regression model, the corrected complication hazard of a DDD pacemaker implantation was increased by 3.9 (1.4-11.3) compared to VVI and increased by 2.3 (1.1-4.5) compared to VDD pacing. Higher complication rates in DDD pacing were mainly due to a higher incidence of early reoperation for atrial lead dysfunction, whereas the long-term complication rate was not different from VDD or VVI pacing. Early and long-term complication rates did not differ between VDD and VVI pacemaker systems. In conclusion, operation time and complication rates of physiological pacing are reduced by VDD pacemaker implantation achieving values comparable to VVI pacing. Thus, single lead VDD pacing can be recommended for patients with AV block.     

Spontaneous Twisting of an Implanted Pacemaker Electrode in Three Cases

We present three cases of an unusual pacing lead aberration occurring at different times after implantation. In the first patient, the electrode was twisted close to the pacemaker, and dislodgment occurred on the 40th postoperative day. In the second case, there was only proximal twisting of the electrode. In the third case the electrode was twisted in two places: proximal to the pacemaker, and distal, within the right atrium. The complication was managed successfully by reimplanting the same electrode after stiffening the lead near the generator with a portion of the stylet.     

Uncomplicated heart and lung perforation by a displaced ventricular pacemaker lead: a case report

Lead perforation is a rare complication of pacemaker implantation and associated with the risk of disastrous results like cardiac tamponade or pneumo-hemothorax. We report a patient in whom a ventricular lead perforated the right ventricle and left lung parenchyma without the development of cardiac tamponade, pneumothorax, or hemothorax. No objective evidence for perforation was found on echocardiographic evaluation and thorax computed tomography has made the definite diagnosis. In the literature available to us, it is the first reported case of an uncomplicated right ventricular and lung parenchymal perforation associated with pacemaker implantation.     

Infections in Transvenous Cardiac Pacemakers: Two More Cases

Two patients with metastatic pacemaker infections, one caused by Pseudomonas aeruginosa, 5 months after implantation, and the second by Streptococcus pneumoniae, 8 years after implantation, were treated successfully by removal of the pacemaker systems. Infection reoccurred in the patient with Pseudomonas aeruginosa, who initially underwent partial pacing system removal allowing the atrial lead to remain. Repeat partial atrial lead removal and contralateral pacemaker implantation was followed by clinical infection, which was resolved when both the implanted atrial lead fragment and the recently implanted pacemaker were both removed. Removal of all hardware is required for cure of pacemaker infection.     

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.     

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.     

Three-Year Experience with a Stylet for Lead Extraction: A Multicenter Study

The extraction of chronically implanted and infected pacemaker and defibrillator leads is an important issue. This article describes the experience gathered between 1990 and 1994 by seven European centers regarding a locking stylet that is uniformly applicable for a wide variety of internal pacing coil diameters. This interventional locking stylet for lead extraction has an outer diameter of 0.4 mm (0.016 inches). The stylet consists of a hollow shaft in which an inner traction wire is embedded. At the tip of the inner traction wire an anchoring mechanism, which can be opened by retraction, is applied. Removal attempts were made for 150 leads, 110 in ventricular and 40 in atrial positions. Results : Complete removal was possible in 122 cases (81 %). Partial removal was possible in 18 cases (12%). Failure to remove the lead with the extraction stylet was experienced in 10 cases (7%). In seven patients, the leads were removed by cardiothoracic surgery; 3 defective leads were left in place. There were no serious complications associated with the procedure. None of the patients died. Conclusion : The experience with this extraction stylet for lead removal has shown good results. Despite a low complication rate thus far, each case for lead removal should be judged on the individual basis of benefit-to-risk ratio.     

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.     

Permanent Atrial Pacing in Cardiac Transplant Patients

Thirteen out of 223 consecutive cardiac transplant patients required permanent pacemaker implantation; 11 for sinus node dysfunction and 2 for complete AV block. Patients with sinus node dysfunction were considered for AAIB mode pacemakers if they had intact AV conduction defined as a Wenckebach point of > 120 beats/min. Ten of 11 patients with sinus node dysfunction had a single atrial lead placed. Atrial lead placement was most easily accomplished with a straight, active fixation lead and the use of manually curved stylets to find an optimal position in the donor atrium, although active fixation leads with a preformed atrial J were used as well. Two leads dislodged requiring revision. In contrast, only 1 of 250 atrial leads implanted in nontranspianted hearts dislodged (P < 0.0001). Transvenous endomyocardial biopsies have not caused atrial lead dislodgment. Most transplant recipients requiring permanent pacing have intact AV nodal function and require only atrial pacing. Atrial lead dislodgment requiring lead revision occurs more frequently in heart transplant recipients than in native hearts. Use of a straight active fixation lead with a munually formed curve in the stylet is useful in order to find the optimal position for pacing.     

Delayed pericarditis associated with an implantable cardioverter defibrillator implantation using an active-fixation atrial lead

A 57-year-old man with nonischemic dilated cardiomyopathy and ventricular tachycardia underwent routine dual chamber implantable cardioverter defibrillator (ICD) implantation. An active-fixation atrial lead was positioned at the lateral wall of the right atrium. He subsequently developed chronic severe pericarditis. Histopathological findings of the pericardium showed mechanical stimulus localized pericarditis. This case demonstrates that contact of the screw of the active-fixation atrial lead with the pericardium may be a possible mechanism for pericarditis after pacemaker/ICD implantation.     

Atrio-ventricular synchronization by single VDD lead inserted through persistent left superior vena cava in patient with Turner's syndrome

A 71-year-old woman with Turner's syndrome underwent pacemaker implantation for complete atrio-ventricular block. During the procedure, the persistence of left sided superior vena cava (LSVC) was observed such that the lead, through the coronary sinus, reached the right atrium. By use of stylets, we could drive the lead against the lateral atrial wall and curve it through the tricuspid valve into the right ventricle. The tip reached an apical stable position, obtaining proper stimulation values. Moreover, the VDD dipole was positioned against high lateral atrial wall, adequately sensing the atrial potential. So, we could obtain an atrial synchronous ventricular pacing with only one VDD lead.     

Mechanism of decrease in the atrial potential after implantation of a single-lead VDD pacemaker: atrial histological changes after implantation of a VDD pacemaker lead in dogs

The single-lead VDD pacemaker system (VDDPS) enables atrial synchronous ventricular pacing with only one lead in patients with an atrioventricular block. There are some cases in which the atrial potential decreases after implantation of a VDDPS, making physiological pacing difficult. The mechanism of this decrease has not been elucidated yet. To elucidate the possible relationship between the decrease of the atrial potential after implantation of a VDDPS and histopathological changes of the atrium. We implanted a VDDPS from the jugular vein under anesthesia in 10 adult dogs. The tip of the pacing lead was fixed in the right ventricular apex of the heart under fluoroscopic guidance. Then, the lead was ligated and fixed to the jugular vein at a point where a favorable atrial potential was obtained. The end of the lead was passed from the neck to the back subcutaneously; then pulled outside and fixed there to measure the atrial potential. The atrial potential was measured using a pacing system analyzer under anesthesia on days 3 (n = 9) and 7 (n = 8), as well as on weeks 2 (n = 6), 3 (n = 4), and 4 (n = 3), after the implantation. The heart was removed from the dogs on day 3 (n = 2), day 7 (n = 2), week 2 (n = 2), and week 4 (n = 4) to examine the atrial histological findings. The atrial potential was 2.7 +/- 0.7 mV at the time of the implantation, 1.7 +/- 1.1 mV (P < 0.05) on day 3, and 1.7 +/- 0.7 mV on week 4 after the implantation. Macroscopically, the pacemaker lead was covered with thrombus, and adhered to the atrial wall in 80% of animals. Microscopically, the endocardium was hypertrophic due to fibrous tissue; besides RBC extravasation, inflammatory cells infiltration and degeneration of myocardial cells, were observed under the endocardium. Inflammatory changes developed in the atrial wall after implantation of the VDDPS, and this seemed to be one of the mechanisms for the decrease of the atrial potential of the VDDPS.