Aortic perforation by active-fixation atrial pacing lead

This report describes perforation of the aorta related to the implantation of an active-fixation atrial pacing lead, a previously undocumented complication of pacemaker implantation. The complication was related to excessive tissue penetration by the screw at the tip of the lead or perforation of the lead body by the positioning stylet during manipulation whereupon the stylet traversed the atrial wall and aortic wall. Perforation of the aorta should be part of the differential diagnosis of cardiac tamponade after pacemaker implantation.     

Early Diagnosis and Rescue Pericardiocentesis for Acute Cardiac Tamponade during Radiofrequency Ablation for Arrhythmias. Is Fluoroscopy Enough?

Background: With the number of complex catheter ablation procedures increasing, procedure‐related acute cardiac tamponade is encountered more frequently in the cardiac catheterization laboratory. Survival depends on prompt recognition and rescue pericardiocentesis. Objective: The aim of this report was to validate fluoroscopic heart silhouette characteristics associated with cardiac tamponade as a diagnostic method, and evaluate the safety and effectiveness of fluoroscopy‐guided pericardiocentesis during catheter ablation. Methods: All cases of acute cardiac tamponade that occurred in the cardiac catheterization laboratory during radiofrequency catheter ablation from March 2004 to November 2009 were reviewed retrospectively. Results: Of 1,832 catheter ablation procedures performed during a 5‐year period, 10 (0.55%) were complicated by cardiac tamponade. Fluoroscopic examination confirmed the diagnosis in all 10 patients and demonstrated effusions before hypotension in four patients. All patients were stabilized by fluoroscopy‐guided pericardiocentesis with placement of an indwelling catheter and autologous transfusion. The time interval between recognition of cardiac tamponade and completion of pericardiocentesis was 6.0 ± 1.8 minutes (range 3–9 minutes). The mean aspirated blood volume was 437 mL (range 110–1,400 mL), and the mean autotransfused blood volume was 425 mL (range 100–1,384 mL). Surgical repair of the cardiac perforation was needed in one patient. No procedure‐related death occurred. Conclusion: A reduction in the excursion of cardiac silhouette on fluoroscopy is an early diagnostic sign of cardiac tamponade during radiofrequency ablation. Fluoroscopy‐guided pericardiocentesis is a safe and effective management strategy for cardiac tamponade developed in the cardiac catheterization laboratory. (PACE 2011; 9–14)     

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.     

Recurrent postcardiac injury syndrome mimicking cardiac perforation following transvenous pacing: An unusual presentation

We report a case of recurrent postcardiac injury syndrome (PCIS) after pacemaker lead insertion. Each episode was attended by hemorrhagic pleuro-pericardial effusion with drop in hemoglobin levels leading us to consider cardiac perforation and subject the patient to surgical pericardiotomy. However, no perforation or active bleeding was detected on exploration. This unusual case illustrates the occurrence of PCIS following pacemaker lead insertion, mimicking cardiac perforation. This entity should be considered in patients who, after pacemaker lead insertion, develop pericardial and pleural effusion associated with markers of inflammation.     

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.     

A New Endocardial "Over-the-Wire" or Stylet-Driven Left Ventricular Lead:

Transvenous left ventricular (LV) leads are primarily inserted "over-the-wire" (OTW). However, a stylet-driven (SD) approach may be a helpful alternative. A new polyurethane-coated, unipolar LV lead can be placed either by a stylet or a guide wire, which can be inserted into the lead body from both ends. The multicenter OVID study evaluates the clinical performance of this new steroid- and nonsteroid eluting lead. The primary endpoint is the LV lead implant success rate after identification of the coronary sinus (CS). Secondary endpoints include complication rate, short- and long-term lead characteristics, overall procedure and LV lead placement duration, total fluoroscopy time, and lead handling characteristics ratings. To date, 96 patients with heart failure (68 ± 9 years old, 76% men) are enrolled. The CS was identified in 95 patients and, in 85 (88.5%), the LV lead was successfully implanted. The final lead positioning was lateral in 41%, posterolateral in 35%, anterolateral in 18%, and great cardiac vein in 6% of patients. In 70%, the 85 successful implantations, both stylet-driven and guide-wire techniques were used, a stylet only was used in 22%, and a guide wire only in 8%. Mean overall duration of 85 successful procedures was 112 ± 40 minutes, total fluoroscopy time 28 ± 15 minutes, and the duration of LV lead placement was 35 ± 29 minutes. During a 3-month follow-up, the loss of LV capture occurred in three and phrenic nerve stimulation in six patients. The mean long-term pacing threshold is 0.8 V/0.5 ms and pacing impedance is 550 Ω. The OVID data suggest that these new leads are safe and effective. The choice of both OTW and SD techniques during lead implantation offers greater procedural flexibility.     

Update on small-diameter implantable cardioverter-defibrillator leads performance

Background: The performance of small diameter implantable cardioverter defibrillator (ICD) leads is questionable. However, data on performance during long‐term follow‐up are scarce. The aim of this study is to provide an update for the lead failure and cardiac perforation rate of Medtronic's Sprint Fidelis ICD lead (Medtronic Inc., Minneapolis, MN, USA) and St. Jude Medical's Riata ICD lead (St. Jude Medical Inc., St. Paul, MN, USA). Methods: Since 1996, all ICD system implantations at the Leiden University Medical Center, the Netherlands, are registered. For this study, data up to February 2011 on 396 Sprint Fidelis leads (follow‐up 3.4 ± 1.5 years), 165 8‐French (F) Riata leads (follow‐up 4.6 ± 2.6 years), and 30 7‐F Riata leads (follow‐up 2.9 ± 1.3 years) were compared with a benchmark cohort of 1,602 ICD leads (follow‐up 3.4 ± 2.7 years) and assessed for the occurrence of lead failure and cardiac perforation. Results: During follow‐up, the yearly lead failure rate of the Sprint Fidelis lead, 7‐F Riata lead, 8‐F Riata lead, and the benchmark cohort was 3.54%, 2.28%, 0.78%, and 1.14%, respectively. In comparison to the benchmark cohort, the adjusted hazard ratio of lead failure was 3.7 (95% confidence interval [CI] 2.4–5.7, P < 0.001) for the Sprint Fidelis lead and 4.2 (95% CI 1.0–18.0, P < 0.05) for the 7‐F Riata lead. One cardiac perforation was observed (3.3%) in the 7‐F Riata group versus none in the 8‐F Riata and Sprint Fidelis lead population. Conclusion: The current update demonstrates that the risk of lead failure during long‐term follow‐up is significantly increased for both the Sprint Fidelis and the 7‐F Riata lead in comparison to the benchmark cohort. Only one cardiac perforation occurred. (PACE 2012; 35:652–658)     

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.     

A new endocardial "over-the-wire" or stylet-driven left ventricular lead: first clinical experience

Transvenous left ventricular (LV) leads are primarily inserted "over-the-wire" (OTW). However, a stylet-driven (SD) approach may be a helpful alternative. A new polyurethane-coated, unipolar LV lead can be placed either by a stylet or a guide wire, which can be inserted into the lead body from both ends. The multicenter OVID study evaluates the clinical performance of this new steroid- and nonsteroid eluting lead. The primary endpoint is the LV lead implant success rate after identification of the coronary sinus (CS). Secondary endpoints include complication rate, short- and long-term lead characteristics, overall procedure and LV lead placement duration, total fluoroscopy time, and lead handling characteristics ratings. To date, 96 patients with heart failure (68 +/- 9 years old, 76% men) are enrolled. The CS was identified in 95 patients and, in 85 (88.5%), the LV lead was successfully implanted. The final lead positioning was lateral in 41%, posterolateral in 35%, anterolateral in 18%, and great cardiac vein in 6% of patients. In 70%, the 85 successful implantations, both stylet-driven and guide-wire techniques were used, a stylet only was used in 22%, and a guide wire only in 8%. Mean overall duration of 85 successful procedures was 112 +/- 40 minutes, total fluoroscopy time 28 +/- 15 minutes, and the duration of LV lead placement was 35 +/- 29 minutes. During a 3-month follow-up, the loss of LV capture occurred in three and phrenic nerve stimulation in six patients. The mean long-term pacing threshold is 0.8 V/0.5 ms and pacing impedance is 550 Omega. The OVID data suggest that these new leads are safe and effective. The choice of both OTW and SD techniques during lead implantation offers greater procedural flexibility.     

Use of the mechanical dilator sheath for removal of endocardial leads: a single center experience

Background: Due to an increasing number of cardiac device implantations, the number of leads that need to be extracted because of infection or lead failure is consistently rising. We present our experience in percutaneous lead removal in a single tertiary center. Methods: From December 2009 to August 2010, 12 patients underwent percutaneous lead extraction procedure by the Evolution? mechanical dilator sheath (Cook Medical Inc., Bloomington, IN, USA) system after failure of manual traction and a locking stylet. Results: Ages of the patients ranged between 7 and 86 years (mean age was 58 ± 12 years). Mean implantation time was 73 months (range between 12 and 244 months). Ten patients had one lead; only two patients had two leads. Indications for lead removal were: lead endocarditis in five patients, local (pocket) infection in four patients, and lead failure in three patients. All leads were successfully removed by using the device, except one lead which was one of the two leads in a patient with dual chamber pacemaker implanted 10 years ago. In three patients, same venous accesses (sheath of extraction system) were used to implant a new lead after removal of damaged leads without a new venous puncture. In only one patient, significant hematoma was found after the intervention and treated conservatively. No other significant complications were encountered in any patients. Conclusions: Damaged or infected leads can safely and relatively easily be extracted by using this new percutaneous extraction technique. (PACE 2012; 1–5)     

Anatomical Findings in Patients Having Had a Chronically Indwelling Coronary Sinus Defibrillation Lead

The purpose of this report is to review the gross and histological cardiac anatomical findings in patients with chronically indwelling coronary sinus leads at the time of autopsy or cardiac transplantation. Transvenous cardioverter defibrillators offer effective protection against sudden death. The use of a coronary sinus electrode has been shown in some patients to decrease the defibrillation threshold. The anatomical consequences of chronically indwelling coronary sinus cardioversion /defibrillation electrodes in patients having transvenous implantable cardioverter defibrillators is unknown. The hearts of seven patients with chronically indwelling coronary sinus electrodes were evaluated following autopsy (n= 2) or cardiac transplantation (n= 5), The coronary sinus electrode in each case was a 6.5 French silicon lead with a 5-cm long defibrillation coil (Medtronic CS lead model 6933) that was positioned as distally as possible within the coronary sinus at the time of implantable cardioverter defibrillator surgery. The seven hearts examined were derived from patients whose age ranged between 49 and 69 (mean 56 ± 7 years). Six had coronary artery disease and one had idiopathic dilated cardiomyopathy. The time from implant to death or cardiac transplantation was 8 ± 6 months, range 1–18 months. In all seven patients, there was no evidence of any significant damage from the presence of the coronary sinus lead. The only finding in each case was the scattered presence of a thin white fibrous sheath over the lead that intermittently adhered to the coronary sinus endothelium and, in the two patients transplanted 1–3 months after implantable cardioverter defibrillator insertion, a mild inflammation reaction adjacent to the leads in the coronary sinus endothelium. There was no evidence of coronary sinus occlusion, adjacent coronary artery injury, coronary sinus perforation, coronary sinus burn, or myocardial injury adjacent to the lead. Cause of death was due to end-stage congestive heart failure and thrombotic stroke, respectively, in the two patients examined at autopsy. Coronary sinus defibrillation leads can be used safely without harmful anatomical effect.     

The right ventricular outflow tract: a comparative study of septal, anterior wall, and free wall pacing

BACKGROUND: There is marked heterogeneity in right ventricular outflow tract (RVOT) pacemaker lead placement using conventional leads. As a result, we have sought to identify a reproducible way of placing a ventricular lead onto the RVOT septum. METHODS AND RESULTS: A major determinant is the shape of the stylet used to deliver the active-fixation lead. We compared stylet shapes and configurations in patients who initially had a ventricular lead placed onto the anterior or free wall of the RVOT and then had the lead repositioned onto the septum. All leads were loaded with a stylet fashioned with a distal primary curve to facilitate delivery of the lead to the pulmonary artery, then using a pullback technique the lead was retracted to the RVOT. All lead placements were confirmed by fluoroscopy and electrocardiography. Anterior or free wall placement was achieved by the stylet having either the standard curve or an added distal anterior angulation. In contrast, septal lead positioning was uniformly achieved by a distal posterior angulation of the curved stylet. This difference in tip shape was highly predictive for septal placement (P < 0.001). With septal pacing, a narrower QRS duration was noted, compared to anterior or free wall pacing (136 vs 155 ms, P < 0.001). All pacing parameters were within acceptable limits. CONCLUSION: Using appropriately shaped stylets, pacing leads can now be placed into specific positions within the RVOT and in particular septal pacing can be reliably and reproducibly achieved. This is an important step in the standardization of lead placement in the RVOT.     

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.     

Ultrasonic Assisted Permanent Pacing in a Patient with Severe Pulmonary Tuberculosis

A 67-year-old male patient with previous history of pulmonary tuberculosis presented with syncope due to complete heart block. Collapse of the right lung and deviation of the heart to the right chest had prevented visualization of the cardiac silhouette by fluoroscopy. Successful endocardial permanent pacing using a passive fixation electrode was achieved with the help of ultrasonic visualization of the cardiac chambers.     

Intravascular Extraction of Chronic Pacemaker Leads: Efficacy and Follow-Up

Extraction of chronic pacemaker leads has been recommended for infections, prevention of venous thrombosis, migration, and possible perforation. Success with constant traction techniques has been variable, and the cost and morbidity of open chest surgical procedures are prohibitive. Efficacy of a new system for lead extraction using intravascular techniques was analyzed. The system (Cook Pacemaker) uses a locking stylet, which is secured at the distal electrode by counterclockwise rotation to reinforce the lead and facilitate traction, and dilator sheaths that are used to free the lead from adhesions in the venous system. In a series of 56 patients (ages 19–88)who presented for lead extraction because of erosion (5), infection (14), lead replacement (35), or other (2), 86 leads were extracted. Thirty-two were atrial leads and 54 ventricular; 23 had active fixation and 63 passive. Average duration of implant was 58 ±42 months (range 1–264). Eighty-four leads were totally removed and two partially removed. For these two leads, the distal tip was not removed; in both cases the locking stylet was not secured at the distal electrode due to obstruction within the lead. Two patients developed arm edema following the procedure, which resolved with elevation. One patient developed a subclavian thrombosis, which resolved with warfarin anticoagulation. Four patients have expired due to unrelated causes. In conclusion, this intravascular approach for extraction of chronic leads is effective, and the procedure is safe when performed by experienced personnel.     

Effectiveness of excimer laser-assisted pacing and ICD lead extraction in children and young adults

BACKGROUND: High capture thresholds, decreased electrical sensing, and lead fractures continue to be a problem in children undergoing transvenous pacing. The clinician must therefore decide at the time of pacing system revision to either abandon chronically implanted transvenous pacing leads or extract them. METHODS: We report our experience using an excimer laser-assisted (LA) strategy for removing chronically implanted pacing (36) and implantable cardioverter/defibrillator (ICD) (7) leads in children and young adults. The study population consisted of 25 patients, in whom 29 procedures were performed. The patients ranged in age from 8.4 to 39.9 years, median age was 13.9 years, at the time of the extraction procedure. In all procedures, a Spectranectics locking stylet and excimer laser sheath were used to assist in lead extraction. RESULTS: Lead removal was complete for 39 (91%) leads, and partial for four leads. In two patients, the pacing lead tip was retained and in two, the ring electrode from a bipolar pacing lead was left in situ. All ICD leads were removed completely. Two major complications occurred--cardiac perforation and tamponade (1), and thrombosis of the left subclavian/innominate vein (1). LA extraction facilitated the implantation of new pacing or ICD leads in three patients with obstructed venous access. CONCLUSIONS: Removal of pacing and ICD leads using an excimer LA technique was highly successful. Lead removal was complete in 91%. The most common indication for lead removal in our study was lead fracture. Complications were few, but may be significant.     

Late perforation of the heart, pericardium, and diaphragm by an active-fixation ventricular lead

This case report describes a late perforation of right heart wall, pericardium, and diaphragm by an active-fixation ventricular lead without development of pericardial effusion and cardiac tamponade even under oral warfarin treatment.     

Sheathless implantation of permanent coronary sinus-LV pacing leads

BACKGROUND: Implantation of CS-LV pacing leads is usually accomplished through specialized sheaths with additional use of contrast venography and other steps. Direct implantation at a target pacing site could provide a simplified procedure with appropriate leads. METHODS: A progressive CS-LV lead implant protocol was used, with initial attempts made to place the lead directly using only fluoroscopy and lead stylet or wire manipulation. Coronary sinus (CS) sheaths were only used later if direct lead placement failed. RESULTS: There were 105 attempted implants with 96% (101/105) success. Leads were implanted sheathlessly in 69% (70/101) cases. Pacing parameters and final lead position did not differ significantly between implants that did or did not require sheaths for implants. Three peri-procedural complications occurred in implants where sheaths were used. In 33% (33/101) of implants, the leads were placed without the use of sheaths or contrast venography in 20 minutes or less. CONCLUSIONS: Direct placement of the CS-LV pacing lead without sheaths can be accomplished successfully in a majority of implants and in < or =20 minutes in a third, without inferior pacing parameters. This may provide for shorter or less technically difficult or expensive procedures with low risk.     

Long-term follow-up of left ventricular pacing via a posterior cardiac vein after mechanical tricuspid valve replacement

Permanent cardiac pacing was recommended in a 66-year-old woman with mechanical prosthetic mitral and tricuspid valves. To avoid a thoracotomy, a conventional endocardial lead was inserted with a steerable stylet (Locator) into the posterior cardiac vein via the right cephalic vein. Four weeks later, lead dislodgement required reoperation. The lead position remained stable up to 29 months.     

Cardiac pacing: memories of a bygone era

The first cardiac pacemaker implants occurred in the late 1950s and involved insertion of epicardial or epimyocardial leads and abdominal pulse generators. By the mid 1960s, cardiologists were making attempts to insert transvenous leads into the right ventricle. These early unipolar leads had large, polished, high polarization electrodes, no fixation device, and no lumen in which to place a stylet for lead positioning. The lead implantation procedures were usually long and the irradiation to both patient and operator excessive. Pulse generators were powered by zinc-mercury cells, which were large, unreliable, and prone to sudden output failure. Postoperative complications such as lead dislodgement, exit block, and premature power source failure were very common with most patients requiring further surgery within a year. Little has been written of this period and in particular the experiences of the operators, such that today's pacemaker implanters have virtually no knowledge of this bygone era. This historical report by four Australian cardiologists details the operative procedures and follow-up management of those original pacemaker recipients.