Initial experience with a sutureless, screw-in electrode for cardiac pacing

This report is based on our initial experience with a new sutureless, corkscrew electrode for cardiac pacing. The electrode may be inserted quickly and securely under direct vision through a small anterior mediastinal or transxiphoid incision. This technique, which was employed in 26 patients between July, 1971, and December, 1972, was developed in an attempt to gain the advantages of both the pervenous and epicardial approaches, i.e., secure placement of the electrode in the myocardium with a minor, well-tolerated procedure that can be performed under local anesthesia. Results to date are very promising and indicate that the technique may very well become the method of choice in the future.     

Further evaluation of the sutureless, screw-in electrode for cardiac pacing. Experience with first 300 implantations.

This report details our experience with 300 sutureless epicardial electrode implantations performed in the past 6 years. Indications for pacing, surgical approaches, implantation sites and complications are presented. The subxiphoid approach was valuable in obtaining safe, reliable, and long-term impulse generation. Complications have been few and of short duration. In general, pacing thresholds have been lower and sensitivity thresholds higher with left ventricular implantation than with right ventricular implantation. Endocarcial pacing is reserved for the very aged and debilitated patients, patients requiring implantation within 4 to 6 weeks of acute myocardial infarction, and for atrial or atrioventricular sequential pacing.     

A case of permanent pacemaker implantation in small infant using steroid-eluting epicardial pacing lead: changes of the pacing threshold in acute phase]

A 1-year-old infant with complete atrioventricular block was successfully treated with the pacemaker implantation using steroid-eluting epicardial pacing lead by the subxyphoid approach. Pacing threshold after implantation were measured frequently to use the function named "Capture management" of the generator (Medtronic: Kappa, Model 701). The postoperative pacing threshold were kept lower and stabilized after 5 weeks.     

A 20-year study of endocardial pacing lead EMT 588. Lead durability and nature of failure

A report is presented of 1253 EMT 588 endocardial leads implanted in 1063 patients. The electrode surface area was large (47 mm2) in the 473 leads implanted during 1962-1973, and small (8-12 mm2) in the 780 leads implanted in 1974-1981. Replacement of 245 leads was necessary, in 187 cases due to lead failure and in 58 because of problems with normally functioning leads, such as infection. The highest lead failure rate occurred within the first 6 months after implantation, and was mostly caused by displacement and threshold increase. The dominating cause of late failure was lead lesion. The cumulative lead survival rates for the first and the second series were 88 and 94%, respectively after 1 year, 80 and 91% after 5 years, and 72 and 84% after 9 years. The polyethylene insulation proved to be the most vulnerable part of this lead. Insulation lesions could result in corrosion and/or fracture of the steel conductors. The chronic thresholds were largely stable.     

Case of epicardial left ventricular pacing lead implantation under general anesthesia in a patient with severe cardiac dysfunction

An 82-year-old man with severe cardiac dysfunction due to ischemic cardiac myopathy was diagnosed as indication for biventricular pacing. His left ventricular ejection fraction was 22%. Because of difficulty in coronary sinus lead fixation, epicardial lead implantation through a thoracotomy under general anesthesia was scheduled. Intraaortic balloon pumping (IABP) was started prior to the operation. Anesthesia was induced by midazolam and fentanyl, and maintained with fentanyl and low dose propofol infusion. Milrinone was infused throughout the operation. Except for just after the anesthesia induction, systolic blood pressure was kept well around 100 mmHg. The operation was completed without any ploblems. NYHA classification improved markedly (class IV to class II) by biventricular pacing. Using IABP, we could maintain blood pressure and stabilize hemodynamics during left ventricular lead implantation in a patient with severe heart failure.     

Clinical evaluation of combination therapy for biventricular pacing after cardiac surgery in patients with intractable heart failure.

We examined the effectiveness of combination therapy for biventricular pacing after cardiac surgery. We performed biventricular pacing in seven patients until April 2003. The diagnosis of the patients was ischemic cardiomyopathy (ICM) in four patients and dilated cardiomyopathy (DCM) in three patients. The implantation method of biventricular pacing was performed with a myocardial electrode through a median sternotomy. DDD-R and SSI-R were used to perform biventricular pacing. A Y-adapter was connected to a generator so that the 2 leads could be implanted in both the right ventricles (RV) and left ventricles (LV). The clinical symptoms were New York Heart Association (NYHA) classification of 3.7+/-0.3 preoperatively and 1.8+/-0.6 postoperatively, showing a significant improvement (p<0.001). The cardiac index (CI) was 1.9+/-0.2 L/min/m2 preoperatively and 3.0+/-0.6 L/min/m2 postoperatively (p<0.05). The pulmonary capillary wedge pressure (PCWP) was 19.5+/-2.6 mmHg preoperatively and 13.6+/-2.0 mmHg postoperatively, showing a significant improvement (p<0.05). The intracardiac potential and threshold values were: left atrium 1.9+/-1.0 mV, threshold value (PW: 0.45 msec) 2.1+/-0.6 V, LV 4.9+/-4.23 mV, threshold value (PW: 0.45 msec) 2.2+/-1.51 V, and RV 3.6+/-0.9 V, threshold value (PW: 0.45 msec) 2.0+/-0.7 V. The LV and RV threshold values were high. The QRS interval improved from 158.4+/-18.0 msec preoperatively to 110+/-13.4 msec postoperatively, showing a significant reduction. This combination therapy when compared to the use of the biventricular pacing method used at the current time, does have the risks of cardiac surgery, but the clinical symptoms and hemodynamic performance improvement are great.     

Venous occlusion: a rare complication of transvenous cardiac pacing.

Venous occlusion is an uncommon complication of transvenous cardiac pacing. Fibrotic occlusion of the right subclavian and innominate veins and stenosis of the left innominate vein, after the insertion of transvenous pacing wire, was corrected surgically with an external iliac vein graft.     

Prospective evaluation of ureteral stent durability in patients with chronic ureteral obstruction

Objectives. To prospectively evaluate the durability of ureteral stents in patients with chronic ureteral obstruction.Methods. Twenty-nine renal units from 22 patients with known chronic ureteral obstruction treated with indwelling ureteral stents were studied at 3, 6, 9, and 12 months after initial stent placement (7 to 8F Percuflex) by abdominal x-ray, serum creatinine, and renal and bladder ultrasonography. Renal ultrasound scans were performed by a single senior radiologist with specific attention paid to any increase in hydronephrosis and to the presence of ureteral jets. The stent was changed when calcifications were seen along the stent on abdominal x-ray, if an increase in serum creatinine occurred, or if any increase in hydronephrosis or absence of ureteral jets was seen on ultrasonography. In addition, the stents were changed if new-onset flank pain and/or pyelonephritis developed. If none of the above occurred, the stents were changed after 12 months.Results. Two patients died of metastatic cancer, leaving 25 renal units available for follow-up. The mean and median time to stent change were 6 months. At 3, 6, 9, and 12 months, the number of renal units that did not meet the criteria warranting stent change was 18 (72%), 12 (48%), 6 (24%), and 2 (8%), respectively. Only 2 (8%) of 25 renal units did not meet any exclusion criteria at 12 months. The most common reasons for requiring the stent to be changed were new-onset flank pain in 8 (35%), an increase in serum creatinine in 7 (30%), and new-onset or increased hydronephrosis in 7 (30%). No criteria were useful in predicting how long stents could be maintained in an individual patient.Conclusions. The stents were maintained for more than 6 months in 12 (48%) of 25 renal units. However, very few patients were able to maintain chronic ureteral stents for 12 months without requiring stent change based on our criteria.     

Arteriovenous fistulae complicating cardiac pacemaker lead extraction: recognition, evaluation, and management

Transvenous pacemaker lead extraction has become a commonly performed procedure that is associated with a small but significant risk. We report two cases where lead extraction was complicated by arteriovenous fistulae between branches of the aortic arch and the left brachiocephalic vein. Presenting signs and symptoms included severe chest or back pain, persistent or copious bleeding from the venous puncture site, unexplained hypotension or anemia, superior vena cava syndrome, and signs of central venous hypertension or acute heart failure. One patient whose injury was not recognized immediately and who did not undergo repair died rapidly, whereas the other patient who was diagnosed quickly underwent successful repair. Immediate diagnosis with arteriography and rapid intervention with surgery or percutaneous techniques are indicated and may prevent mortality.     

Transesophageal echocardiography guided placement of a coronary sinus pacing lead

Cardiac resynchronization therapy for the treatment of medically refractory heart failure requires coronary sinus lead placement for left ventricular pacing. Coronary sinus lead placement is technically difficult with success rates reported between 53% to 98% and implantation times ranging from 90 minutes to 5 hours. We report the use of intraoperative transesophageal echocardiography to guide coronary sinus lead placement when conventional fluoroscopy failed. Transesophageal echocardiography may improve the success rate with coronary sinus lead placement and decrease the operative time required. This should be used with caution, however, as sedation, possible intubation, and esophageal manipulation have potentially morbid consequences in patients with advanced congestive heart failure.     

Temporary epicardial pacing after cardiac surgery: a practical review. Part 2: Selection of epicardial pacing modes and troubleshooting

The first part of this two-part review discussed the indications for various types of epicardial pacing systems and an overview of the routine care of a pacemaker-dependent patient. Dual chamber temporary pulse generators now feature many of the refinements developed initially for use in permanent pacemakers. Few of these are utilised in the immediate postoperative period, often solely due to lack of familiarity with all but basic functions. The second part of the review deals with the selection of pacing modes. Troubleshooting real and apparent pacemaker malfunctions, including manual adjustment of parameters such as the AV interval, post atrial refractory period and upper rate limit, to avoid over- and undersensing, cross-talk and pacemaker-mediated tachycardia will also be addressed.     

Surgical removal of an Accufix pacing lead with a protruding J wire

We report a patient with a fractured J wire protruding through the outer polyurethane sheath of an Accufix electrode in the subclavian vein and right atrium. The wire within the subclavian vein was removed transvenously, while the tip of the lead within the right atrium was removed surgically via a median sternotomy.     

Epicardial corkscrew lead fracture: an underreported cause of pacing failure?

Three children with a pacemaker sustained similar lead fractures within a two-year period. Each fracture occurred in the corkscrew portion of a Medtronic Model 6917 epicardial lead. All patients were boys. The leads had been in place for 12, 45, and 43 months prior to fracture. None of the patients had sustained major trauma. Fracture of the corkscrew lead has been considered an uncommon complication. However, three lead fractures in the corkscrew area in a population of 60 children followed at this institution indicate that this may be a more common cause of pacemaker-system malfunction than previous data suggest. A plea is made for reporting all pacing failure to the manufacturer.     

Superior vena caval stenosis: a rare complication in permanent transvenous cardiac pacing

An unusual case of superior vena caval stenosis associated with a permanent transvenous cardiac pacing wire and its successful treatment by surgical reconstruction using a pericardial patch is reported.     

Clinical evaluation of a new fat removal filter during cardiac surgery.

OBJECTIVES: Fat microemboli are generated during cardiac surgery that are associated with post-operative organ injury. Recently, a fat removal filter has been developed, based on a polyester leukocyte depletion filter. However, the efficacy of such a filter in a clinical setting is unknown. In this study we tested the efficacy of this filter. METHODS: Coronary artery bypass patients were randomly divided into two groups. Group I: filtration of cardiotomy suction blood during cardiopulmonary bypass with a fat removal filter (n=14). Group II: control patients without filtration (n=14). Filter efficacy was evaluated in group I using biochemical assays and thin layer chromatography of blood samples taken simultaneously before and after the filter. In addition, clinical and biochemical markers for organ injury were determined in both groups. RESULTS: The fat filter removed triglycerides (0.9+/-0.08 vs. 0.63+/-0.08 mmol l(-1), P=0.004, paired t-test), leukocytes (4.3+/-0.8 x 10(9) vs. 2.3+/-0.6 x 10(9)l(-1), P=0.03), and platelets (116+/-26 x 10(9) vs. 75+/-21 x 10(9)l(-1), P=0.003) from the blood samples taken before and after the filter. Chromatography showed a significant reduction in free fatty acids, phospholipids and triglycerides. Clinically, leukocyte counts were similar, but platelet counts were higher (181+/-14 x 10(9) vs. 117+/-8.6 x 10(9)l(-1) control, P<0.001) in group I on the first postoperative day. CONCLUSIONS: The fat filter removed 40% fat, leukocytes and platelets from cardiotomy suction blood during cardiac surgery. A larger scale study is necessary to determine clinical effects on organ damage.