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.     

Unusual case of pacemaker lead migration

Pulmonary artery migration of pacemaker lead is rare and may result in pulmonary emboli originating from the thrombus around the infected catheter and causing multiple pulmonary infarcts. We report an unusual case of pacemaker lead migration to the right pulmonary artery with septic pulmonary embolism. While being treated with intravenous Cefuroxamine, the patient had spontaneous migration of the lead to the left pulmonary artery with subsequent left pulmonary embolism.     

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.     

An unusual cause of stroke in a patient with permanent transvenous pacemaker

We report the case of a 61-year-old man with a stroke secondary to cerebral embolism resulting from inadvertent malposition of a permanent transvenous pacemaker lead in the left ventricle. An electrocardiogram and chest X-ray were suggestive of a left-sided positioned lead which was confirmed by transthoracic echocardiography. Because this malposition was complicated with a cerebrovascular event, transcatheter lead extraction was planned, however, the patient chose lifelong anticoagulation therapy.     

Entanglement of embolised thrombus with an endocardial lead causing pacemaker malfunction and subsequent pulmonary embolism.

A 67 year old woman with a permanent pacemaker was admitted with pulmonary oedema and mitral valve incompetence two months after a myocardial infarction. Echocardiograms showed good left ventricular function and a large coil of apparent thrombus in the right atrium prolapsing into the right ventricle. Intermittent loss of pacemaker sensing and capture was noticed on admission and probably caused the supraventricular tachycardia and ventricular fibrillation that occurred before an exploratory bypass operation. At operation rupture of the papillary muscle was found and the mitral valve was replaced. A large piece of thrombus was retrieved from the right pulmonary artery. The right heart contained no clot and the pacemaker wire was not displaced. It is envisaged that the strand of venous thrombus was caught in the permanent pacing wire at the tricuspid valve level resulting in an unusual case of pacemaker malfunction. The eventual poor outcome was almost certainly influenced by the arrhythmias and pulmonary embolism caused by the clot and might have been avoided by early operation.     

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.     

Entanglement of embolised thrombus with an endocardial lead causing pacemaker malfunction and subsequent pulmonary embolism

A 67 year old woman with a permanent pacemaker was admitted with pulmonary oedema and mitral valve incompetence two months after a myocardial infarction. Echocardiograms showed good left ventricular function and a large coil of apparent thrombus in the right atrium prolapsing into the right ventricle. Intermittent loss of pacemaker sensing and capture was noticed on admission and probably caused the supraventricular tachycardia and ventricular fibrillation that occurred before an exploratory bypass operation. At operation rupture of the papillary muscle was found and the mitral valve was replaced. A large piece of thrombus was retrieved from the right pulmonary artery. The right heart contained no clot and the pacemaker wire was not displaced. It is envisaged that the strand of venous thrombus was caught in the permanent pacing wire at the tricuspid valve level resulting in an unusual case of pacemaker malfunction. The eventual poor outcome was almost certainly influenced by the arrhythmias and pulmonary embolism caused by the clot and might have been avoided by early operation.     

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.     

Paradoxical peripheral embolism coincident with acute pulmonary thromboembolism

Paradoxical embolism may occur in patients with acute pulmonary thromboembolism, when patent foramen ovale (PFO) coexists with pulmonary hypertension (right-left shunt). There have been few case reports of paradoxical embolism in peripheral arteries coincident with acute pulmonary thromboembolism. Here, we describe a case of paradoxical peripheral embolism associated with PFO complicated by acute pulmonary thromboembolism. The patient had severe peripheral ischemia due to a massive thrombus and was treated successfully by peripheral thrombectomy, thrombolysis, implantation of a permanent inferior vena cava filter and anticoagulation.     

Multiple-vein thrombosis and pulmonary embolism after pacemaker implantation treated by thrombolysis.

This report describes a patient who suffered multiple-vein thrombosis following permanent pacemaker implantation and developed a pulmonary embolism while on anticoagulation treatment, which was successfully treated by thrombolytic therapy.     

Aspergillus fumigatus pacemaker lead endocarditis: a case report and review of the literature

The diagnosis of fungal endocarditis requires a high index of clinical suspicion. Rarely, pacemaker implantation may be a risk factor for the development of fungal endocarditis. A 71-year-old man with a history of multiple transvenous pacemaker manipulations and fever of an uncertain source is described. A diagnosis of culture-negative pacemaker endocarditis was established only after repeat transthoracic echocardiography. Amphotericin B was instituted; however, the patient developed a cerebral infarct and died. Postmortem examination demonstrated Aspergillus fumigatus within a large pacemaker lead thrombus, tricuspid and aortic valve vegetations, and septic pulmonary and renal emboli. The present report describes the clinical and pathological features of a rare case of Aspergillus fumigatus pacemaker lead endocarditis and suggests that serial echocardiograms may be effective in the early detection of pacemaker lead vegetations. The diagnostic features and therapeutic management of pacemaker lead endocarditis are reviewed.     

Vena caval interruption and pulmonary embolectomy

Surgery for pulmonary embolism has evolved to include intraluminal methods of vena caval filtration for prevention of recurrent pulmonary embolism and transvenous extraction of pulmonary emboli. Though the majority of patients who initially survive pulmonary embolism can be managed medically with anticoagulation, a significant number will require surgical intervention. The development of transvenous methods allows effective emergency management of major pulmonary embolism, even in hospitals that do not have the capability for cardiopulmonary bypass.     

Endocardial pacemaker or defibrillator leads with infected vegetations: a single-center experience and consequences of transvenous extraction

Background

Removal of infected endovascular leads if often required for cure of systemic infection, but the perceived risk of embolic events in the presence of large (>10 mm) vegetations has been considered a relative contraindication to transvenous removal. Surgical removal of pacemaker leads has been suggested in this situation to avoid occurrence of pulmonary embolization.

Methods

Of 38 patients with infection of implanted pacemaker or cardioverter-defibrillator devices, those with evidence for systemic infection underwent transesophageal echocardiography to assess for the presence of vegetations.

Results

Vegetations on endocardial leads or right-sided cardiac structures ranging in size from 10 mm to 38 mm in their largest dimension were detected in 9 patients. All patients underwent successful transvenous removal of endocardial leads. Five of 9 patients (55%) had evidence of pulmonary embolism. However, all 5 patients made a full recovery with antibiotic treatment and anticoagulation. Among patients with endocardial vegetations, there was no difference in hospitalization periods between those with or without pulmonary embolism (14.6 ± 0.8 days vs 18.0 ± 4.5 days, P = .7).

Conclusions

Transvenous removal of infected pacemaker leads is an alternative to open-thoracotomy removal of infected leads. Fifty-five percent of patients with vegetations on endocardial leads in our series experienced pulmonary embolism, but neither survival nor length of hospital stay were affected by this complication.     

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.     

Recurrent pulmonary emboli and thrombus attached to a permanently implanted pacemaker wire in pregnancy.

We present a case of pacer wire thrombus and recurrent pulmonary emboli in pregnancy associated with a permanent pacemaker. Transthoracic echocardiography demonstrated a thrombus attached to the pacer wire at the point where it crossed the tricuspid valve. After the uncomplicated vaginal delivery, thrombolytic therapy was given. This thrombus persisted despite thrombolytic therapy. Consequently, the patient was referred for cardiac surgery. The suspected cause was confirmed during the surgery.     

Pacemaker associated infection due to a corynebacterium species

Pacemaker associated infection (PAI) is a rare but often serious complication of permanent or temporary transvenous cardiac pacemakers. The major risk factor is recent or multiple pacemaker manipulations or surgical procedures. A PAI can occur at the time of insertion, from contiguous spread to the access site, or from transient bacteremia. We report a case of PAI of a retained pacemaker electrode from which a Corynebacterium species was isolated. Multiple preoperative cultures were sterile, but bacteria were isolated from tissue removed at surgery, and were seen around the wire deep inside a thrombus. The importance of cultures and special stains (including electron microscopy) of surgical materials is stressed, especially when dealing with microorganisms of ordinarily low virulence, or those that are commonly considered laboratory contaminants.     

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.     

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."     

Right atrial thrombus and recurrent pulmonary emboli secondary to permanent cardiac pacing--a case report and short review of literature

A patient with a right atrial thrombus and recurrent pulmonary emboli secondary to permanent pacemaker insertion is described. Possible precipitating factors were damage to the subclavian vein, congestive heart failure, paroxysmal atrial fibrillation, and immobilization. Venography demonstrated a large atrial thrombus in the superior vena cava and right atrium. The patient was successfully treated with heparin and subsequently with warfarin and dipyridamole.     

Characteristics of patients with cervical spinal injury requiring permanent pacemaker implantation

Acute cervical spinal cord injury frequently results in bradydysrhythmia, which may lead to hypotension and asystole. Such symptoms are more common in the first 2 weeks after the injury. Treatment modalities include atropine, epinephrine, aminophylline, and pacemaker insertion. The criteria for pacemaker use in this population are not well defined. We describe characteristics of 3 patients who required permanent, transvenous pacemaker implantation for recurrent symptoms. In 2 of the 3 patients, transcutaneous pacing failed to provide adequate protection. Transcutaneous pacemakers are not reliable, as was the case of these patients, and early consideration for transvenous pacemaker insertion may be indicated, especially in hemodynamically unstable patients. In this report, all 3 patients required permanent pacemaker implantation.