Removal of Infected Dual Chambered Transvenous Pacemaker and Implantation of a New Epicardial Dual Chambered Device with Cardiopulmonary Bypass: Experience with Seven Cases

ABAD, C., et.al .: Removal of Infected Dual Chambered Transvenous Pacemaker and Implantation of a New Epicardial Dual Chambered Device with Cardiopulmonary Bypass: Experience with Seven Cases . Seven patients with infected transvenous dual chambered pacemakers have undergone removal of the device using cardiopulmonary bypass. There were four women and three men with a mean age of 58 years. Six patients had localized infection in the generator pocket (mean of 4.6 previous unsuccessful operations for surgical sterilization). Four infections were due to Staphylococcus epidermidis, two to Staphylococcus aureus, and one patient presented septicemia caused by Staphylococcus epidermidis and Pseudomonas aeruginosa. The atrial and ventricular transvenous electrodes were removed under direct vision using cardiopulmonary bypass. A new dual chambered epicardial pacemaker was implanted. The procedure was well-tolerated, and all patients are infection free with working pacemakers after a mean follow-up of 25.4 months.     

Peripheral Migration of Pacemaker Electrodes

A 55-year-old male was admitted with right ileo-femoral phlebitis caused by an unused pacemaker electrode fragment which had migrated from the right subclavian vein to the right iliac vein. Vena cava plication was followed by removal of the electrode fragment and complete resolution of the phlebitis. The exposed metal coil may have contributed to the severe inflammatory reaction.     

Cerebral Embolism Due to Left Ventricular Pacemaker Lead: Removal with Cardiopulmonary Bypass

Malposition of a cardiac pacemaker lead within the left ventricle represents a source of early and late thromboembolic complications. We report a case of cerebral embolism, caused by an inadvertently misplaced left ventricular electrode, occurring 3 years after implantation. The lead was removed via a transaortic approach with extracorporeal circulation.     

Corrosion of Pacemaker Electrodes

As improvements in pacemaker components and design increase pacemaker life, problems with other components may emerge such as corrosion of the electrodes. Explanted electrodes were examined under a scanning electron microscope and the degree of corrosion was graded and correlated with the reasons for expiantation, the status of the explanted pacemaker, and the duration of the implant. Fifty-six explanted electrodes were removed for loss of capture or sensing, pacemaker extrusion, broken wires, or after death. A numerical grading system was used to qualitate the degree of corrosion. The pacemaker itself was retrieved in 50 cases, permitting evaluation of the entire pacing system. The dc component of the pacemaker output was measured. Without She aid of magnification most electrodes appeared shiny and smooth. With one exception all corrosion was microscopic. Significant corrosion was seen on all pacemaker electrodes that had been connected to pacemakers with dc offset currents greater than 5 microamperes. All except the "youngest" explanted electrode showed some degree of corrosion. The data suggest that corrosion was directly related to the duration of implantation. With the possible exception of one case, no consistent adverse clinical effects were observed, even when electrodes were heavily corroded. Whether or not corrosion eventually will progress to the point that clinical problems become manifest cannot be predicted at this time.     

Percutaneous Removal of Infected Permanent Pacemaker Leads Using a Simple Coaxial Dilating System

A simple traction-countertraction technique using common and readily available materials was successfully used to remove infected pacemaker leads from two patients. The specific methodology is presented. Although somewhat technically demanding, this approach appears safe and cost-effective. This method provides another way to remove pacemaker leads without resorting to thoracotomy.     

Surgical Removal of Infected Transvenous Pacemaker Leads

Infection, though uncommon, can be the most lethal of all potential complications following transvenous pacemaker implantation. Eradication of infection associated with pacemakers requires complete removal of all hardware, including inactive leads. Since 1972, 5,089 patients have had 8,508 pacemaker generators implanted at Montefiore Medical Center. There were 91 infections (1.06%); four of our patients required surgical removal. Nine additional patients were referred for surgical removal of infected transvenous pacemaker leads from other institutions. Surgical methods for removal included use of cardiopulmonary bypass or inflow occlusion. Surgery may be safely used in unstable or elderly patients and should not be reserved as a last resort. This article reviews our surgical experience removing infected pacemaker leads at Montefiore Medical Center.     

Extraction of a Chronically Infected Endocardial Screw-in Pacemaker Lead by Pigtail Catheter and Wire Loop Via the Femoral Vein

A 71-year-old woman was admitted after partial removal of an infected pacemaker system. Septicemia and subclavian vein thrombosis were present. With combined use of a pigtail catheter and a wire loop originally developed for endoscopic polypectomy, the infected catheter was pulled into the inferior vena cava. Counterclockwise rotation of the pigtail catheter following its fixation to the electrode by the wire loop allowed removal of the tip of the endocardial screw-in electrode from the myocardium and its extraction. Open heart surgery was avoided and the source of chronic infection was removed.     

Laser Extraction of a Trapped Infected Port Catheter in a Child Using Existing Experience from Pacemaker and ICD Lead Removal

A 9‐year‐old girl presented with systemic infection related to a Port‐a‐Cath system (PAC); therefore, the urgent removal of the PAC was indicated. However, the catheter was trapped and not extractable by conventional means. Using existing comprehensive experience in the removal of pacemaker and implantable cardioverter defibrillator leads, the entrapped PAC was successfully extracted by laser technique, thus avoiding open heart surgery. (PACE 2011; e9–e10)     

Removal of Fractured Pacemaker Electrode Tip Using Dotter Basket

During attempted removal of an infected permanent pacemaker system, the electrode fractured, leaving the tined tip embedded in the wall of the left subclavian vein. The electrode tip was successfully removed using a Dotter basket retrieval kit.     

Extreme Intracardiac Coiling of a Transvenous Pacemaker; A Case Report

We report an unusual complication of transvenous pacing: extreme coiling of a pacemaker catheter, which formed a redundant, twisted loop protruding into the right ventricular outflow tract. This may be a result of "tividdling" (rotation) of the pacemaker generator by the patient and/or inadequate fixation of the catheter at the venous entry site. Careful fixation of the generator to the venous entry site within the subcutaneous pocket may prevent such a complication.     

Successful Removal of a Severed Transvenous Pacemaker Electrode

The ease and simplicity of the transvenous approach to permanent pacing continue to be among its greatest advantages. However in a small proportion of transvenously paced patients complications can occur. A rare complication is an incompletely removed pacing catheter with subsequent embolization to more central parts of the cardiovascular system. This communication reports the migration of a severed transvenous pacemaker electrode and its removal from the left iliac vein with a femoral-ventricular pigtail catheter.     

Serial Lead Impedance Measurements Confirm Fixation of Helical Screw Electrodes During Pacemaker Implantation

The purpose of this study was to determine whether serial measurements of helical screw pacemaker lead impedance could reliably confirm electrode fixation in the right atrium and right ventricle. Fixation is generally assessed fluoroscopically, which can be misleading because the myocardium is radio lucent. Alternatively, because the electrical conductivity of blood is greater than that of myocardium, serial measurements of the lead impedance might be expected to show an impedance increase with appropriate fixation of the pacemaker electrode when the electrode becomes embedded in myocardial tissue. Impedance measurements were made during the placement of 23 atrial and 28 ventricular active fixation electrodes in 31 consecutive patients. Impedance measurements were recorded in unipolar and bipolar electrode configurations with the electrode free floating in the chamber, unfixed (with exposed screws) but touching the endocardial surface, and after fixation. No significant impedance differences were found between free-floating and unfixed electrode positions. With fixation, the lead impedance increased significantly in the ventricle (P = 0.0001, unipolar and bipolar) and the atrium (P = 0.0069 unipolar and 0.0052 bipolar). Typical increases, reflected by median values, were 197 ohms unipolar and 203 ohms bipolar in the ventricle and 47 ohms unipolar and 53 ohms bipolar in the atrium for electrodes with permanently exposed or retractable screw designs. Comparing serial measurements of lead impedance before and after electrode fixation is a valid electrical method of confirming appropriate fixation of helical screw electrodes.     

Inadvertent Transarterial Pacemaker Insertion: An Unusual Complication

We describe an unusual complication of pacemaker treatment in a patient who died after a replacement operation. In a difficult situation in which a functioning pacemaker was highly desirable and in which most of the available veins had already been used, the pacemaker electrode was inserted, by mistake, through a small artery. This was not detected by fluoroscopy during surgery. The postoperative X-ray examination seemed to indicate that the electrode tip was located in the coronary sinus, but the subsequent autopsy revealed it to be located in the left ventricle.     

Pacemaker Follow-Up: Its Role in the Detection and Correction of Pacemaker System Malfunction

The goal of pacemaker follow-up is not only to detect battery depletion but also to detect all malfunctions of the pacing system and, when possible, to correct such problems using programming. During one year, we discovered 61 such malfunctions in a clinic of 1065 patients (5.7%). These were more frequent in the first year (7.7%) than in the third to fifth years of follow-up (range 3.1-4.8%). The incidence rose again in the sixth and subsequent years (7-7.7%). Despite a significant occurrence of malfunctions (5.2%) among multiprogrammable pacemakers, the necessity for operative intervention for their correction was low (1.2%). Sensing problems were the most common (57%) and the most likely to be corrected by reprogramming (85%); problems involving loss of capture were less likely to be corrected by programming (38.5%). Battery depletion accounted for only 18% of malfunctions, occurring earliest in the forty-third month of follow-up. Pulse generator longevity of those devices reaching end of battery life during the study period was 68.6 +/- 16.7 months (mean + SD). We conclude that specialized pacemaker follow-up continues to be necessary despite improved pulse generator reliability and longevity. Indeed, with reprogramming, it presently plays an even more important role than in the past. Follow-up should be oriented not only to the detection of battery depletion but also toward a comprehensive surveillance of pacemaker system function.     

Candida Albicans Pacemaker Site Infection

A 69-year-old man with a history of diabetes and episodic lymphocytopenia underwent pacemaker implantation for complete heart block. Despite prophylactic antibiotics, pocket irrigation, and strict sterile technique, a fungal (Candida albi-cans) pacemaker site infection developed that required pacemaker explantation and systemic ampho-tericin B therapy. After 3 days of temporary pacing, a second pulse generator was implanted on the opposite side. At 2-year follow-up, he has had no recurrence of pacemaker infection. This report underscores the predilection of diabetics for infections, and in particular, their susceptibility to Candida albicans.     

Percutaneous Pacemaker Lead-Transsecting Catheter

We describe the development and successful use of a percutaneous lead-transsection catheter. It was used in two patients in whom removal of chronically implanted atrial pacing leads could not be accomplished by traction.     

Pacemaker Dependency After Coronary Artery Bypass

A retrospective study was carried out on 36 patients (33 males and 3 females) to determine the incidence of WI pacemaker dependency following coronary artery bypass surgery. Pacemaker dependency was defined as the presence of pacemaker activity when pacing rate was programmed at 50 beats/min and/or when no hemodynamic adequate rhythm was present during pulse generator replacement. The patients were divided into two groups: (group I) 26 patients with complete atrioventricular (AV) block developing in the early postoperative period. In most of them a pacemaker was implanted up to 3 weeks following surgery (range 2 days to 1 year); (group II) ten patients in whom the indication for pacemaker implantation was sick sinus syndrome with sinus arrest and/or tachy-bradycardia. These patients underwent pacemaker implantation at varying periods of time following surgery (range 12 days to 4 years). Unipolar endocardial leads with VVI programmable pacemakers were implanted in all patients included in this study. Mean follow-up time was 3 years. In group I the pacemaker dependency rate was 65%, whereas in group II it was 30% throughout the follow-up period. It is concluded that the low incidence of pacemaker dependency in patients who undergo pacemaker implantation after coronary bypass surgery necessitates frequent evaluation in the nondependent patient, in order to reassess the need for the pacemaker before pulse generator replacement. Such reassessment should probably include prolonged ambulatory monitoring as well as invasive evaluation of the conduction system, if avoidance of pulse generator replacement is considered.     

The Dotter Retriever and Pigtail Catheter: Efficacy in Extraction of Chronic Transvenous Pacemaker Leads

Several techniques exist for percutaneous extraction of chronic pacemaker leads. To establish the efficacy of the Dotter retriever and pigtail catheter, we reviewed the removal of 59 endocardial pacemaker leads in 42 patients (mean age 71 years). The mean duration of lead implantation was 44 months (range 1–169 months). Thirty-two leads were withdrawn with simple traction alone, and five leads were abandoned when traction failed. The remaining 22 leads were manipulated with a Dotter retriever or pigtail catheter, or both. Twelve leads were dislodged from the endocardium with simple traction (10)or with traction transmitted through an entwining pigtail catheter (2), but they could not be fully withdraivn. Eleven of these leads (92%)were then successfully extracted with the Dotter retriever. Seven of the remaining 10 leads were successfully disJodged and removed by the Dotter retriever. Overall, 9 of 12 leads (75%)that could not be dislodged from the endocardium with simple traction were removed with a Dotter retriever or pigtail catheter, or both. Three patients in whom no catheter method worked required thoracotomy for removal of infected leads. No complications resulted from use of the Dotter retriever or pigtail catheter. We conclude that the Dotter retriever and pigtail catheter have moderate efficacy for dislodging chronic endocardial leads. Once mobilized, however, the leads can be withdrawn with great success with the Dotter retriever. Newer technology should not result in the abandonment of this proven technique.     

Complications after Single versus Dual Chamber Pacemaker Implantation

To compare the complication rate in patients having a dual chamber versus a single chamber pacing system, 337 consecutive procedures performed during a 3-year period were analyzed prospectively. Two hundred fifty-eight patients (77%) received a VVI pacemaker and 75 (23%) a DDD unit. Thirteen VVI (5%) and 4 DDD (5.3%) needed reintervention. Lead displacement with reoperation was required for three ventricular leads (1%) and one atrial lead (1.3%). Infection occurred in two VVI units (0.77%) and one DDD (1.33%) unit. Muscular stimulation was noticed among three DDD (4%) and nine VVI systems (3.5%). Urgent reprogramming was needed for 23 VVI (9%) and six DDD units (8%). There was no increase in complications with dual chamber pacing compared to single chamber systems.