Transvenous pacemaker malposition in the systemic circulation and pacemaker infection: a case report and review of the literature

Transvenous pacemaker malposition in the systemic circulation is a rare complication of pacemaker implantation; the incidence is not well known. However, with the aid of two-dimensional echocardiography, the problem of pacemaker malposition can be identified earlier. After pacemaker insertion, an electrocardiogram and a posterior-anterior and lateral chest x-ray should be routinely performed. In difficult cases, transthoracic echocardiography and transesophageal echocardiography can be helpful for better visualization and confirmation of the malposition of the pacemaker lead(s). Pacemaker infection is another complication. A case of pacer lead malposition into the left ventricle through a sinus venosus atrial septal defect and superimposed infection is reported, and the management of endocardial lead malposition in the systemic circulation and pacemaker infection is reviewed.     

Perforation of a temporary transvenous pacemaker electrode in the left hemithorax. Diagnostic value of echocardiography]

We report a rare malposition of a temporary transvenous pacemaker electrode. A pacemaker electrode was inserted in a patient with acute postero-lateral infarction. The correct position of the electrode tip was controlled by fluoroscopy. Capture and sensing functions worked regularly. Four days later, angina-pectoris-like complaints occurred again. Chest x-ray film revealed the tip of the electrode in the left hemithorax. Echocardiographic assessment showed a penetration through the interventricular septum into the left ventricle. The electrode passed the left ventricle, penetrated the anterior-lateral free wall and reached the left pleural space. A thoracotomy was performed immediately. The electrode was retracted under visual control. A spurting arterial bleeding from the left ventricle was secured with a purse-string ligature. This case report emphasizes the value of echocardiography in the evaluation of a malposition of a transvenous pacemaker electrode.     

Echocardiographic diagnosis of permanent pacemaker lead malposition in the left ventricle: A case study

Inadvertent endocardial lead malposition is recognized as a rare incident which is usually underreported and if recognized during implantation can be easily corrected. This phenomenon is caused by the ventricular lead unintentionally crossing a pre-existing patent foremen ovale, septal defects (atrial or ventricular) or directly from the aorta via an accidental subclavian puncture resulting in the lead implanting into the left ventricle. While this is a rare occurrence we report, the incidental finding of pacemaker lead malposition during a routine follow-up transthoracic echocardiogram and the benefits of three-dimensional transesophageal echocardiography in this patient prior to lead extraction.     

Echocardiographic Localization of an Inadvertently Placed Pacing Catheter in the Left Ventricle

This report describes a patient in whom a permanent transvenous pacemaker lead was placed unintentionally across the atrial septum and retained in the left ventricle for nearly 11 years before the error was recognized. A 12-lead electrocardiogram showed paced complexes with right bundle branch block configuration. This appearance raised suspicion that the pacemaker electrode might be in the left ventricle and this was confirmed by two-dimensional echocardiography. Two-dimensional echocardiography is useful for the diagnosis of pacing lead malplacement and should be performed in any patient who develops right bundle branch block pattern on the surface electrocardiogram following pacemaker implantation.     

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.     

Prolapsed left atrium behind the left ventricular posterior wall: Two dimensional echocardiographic and angiographlc features

Left atrial enlargement can usually be detected accurately using M mode echocardiography. However, in the presence of heart disease, asymmetric enlargement may lead to inaccurate assessment of left atrial size and shape. Pericardial effusion can usually be diagnosed on the basis of characteristic M mode echocardiographic findings. However, false positive patterns sometimes occur with the use of this single dimensional technique. Three patients with a greatly enlarged left atrium are described whose M mode echocardiogram suggested significant posterior pericardial fluid accumulation. In each patient, two dimensional echocardiography detected portions of a huge left atrium that prolapsed behind the left ventricular posterior wall and mimicked an isolated posterior pericardial effusion. In one case a right anterior oblique left ventricular cineangiogram suggested the presence of a ventricular septal defect or a false aneurysm of the left ventricle due to the prolapsed left atrium. Because two dimensional echocardiography can provide accurate spatial orientation with visualization of intracardiac structures in relation to one another in real time, it can identify the presence of left atrial prolapse and play an important role in the differential diagnosis of isolated echo-free spaces behind the left ventricle detected with M mode echocardiography.     

Asymptomatic left ventricular permanent pacemaker malposition detected on routine follow-up--a case report.

The authors present an asymptomatic left ventricular pacemaker lead malposition that was detected upon routine 2-D Echocardiography. Clinical implication diagnosis and therapeutic options on left ventricular pacemaker lead malposition are discussed.     

Pacemaker electrode misplaced in the left ventricle

This study reports the case of an anomalous implantation of VVI pacemaker electrode in the left ventricle (LV) diagnosed during routine evaluation, two years after implantation. The patient is a 65-year-old woman with Chagas disease. Electrocardiogram (ECG) revealed a pattern of right branch block. Profile chest X-ray showed electrode with posterior curvature path. In transthoracic echocardiography, the diagnosis revealed that the catheter penetrated the right atrium, crossed the atrial septum, descended through the left atrium and mitral valve orifice and deployed on the LV wall. The following related aspects are addressed: potential deployment routes, clinical, radiological, electrocardiographic and echocardiographic pictures, complications and treatment options.     

Utility of Intracardiac Echocardiography for Atrial Baffle Leak Closure in Repaired Transposition of the Great Arteries

A 27‐year‐old male with dextro‐transposition of great arteries had Senning atrial switch repair in childhood and dual‐chamber pacemaker placement for sinus node dysfunction in adulthood. Transthoracic echocardiography showed a lead in the systemic (anatomic right) ventricle. Multidetector computed tomography showed the lead perforating the baffle in the region of the body of the systemic venous atrium into the systemic ventricle. The lead was extracted, and a new lead was placed in the pulmonary (anatomic left) ventricle. A bidirectional baffle shunt persisted. The iatrogenic baffle leak was percutaneously closed with an Amplatzer septal occluder device using both intracardiac echocardiography (ICE) and three‐dimensional transesophageal echocardiography (3D‐TEE). We report the first use of ICE for baffle leak closure, which provided a good definition of the complex anatomy and guided the procedure. (Echocardiography 2010;27:E90‐E93)     

Anatomically corrected malposition of the great arteries, inflow ventricular septal defect, and subaortic stenosis: diagnostic and operative implications

Intracardiac correction of the combination of rare congenital heart lesion of anatomically corrected malposition of the great arteries, severe muscular as well as fibrous subaortic stenosis, and ventricular septal defects in the inflow and the trabecular septum in a 2 1/2 years old boy is reported. There was an additional large secundum atrial septal defect. The operation consisted of resection of the subaortic stenosis by a combined transatrial and transaortic approach, thereby regaining a wide outflow tract of the systemic ventricle. Both the ventricular and atrial septal defects were closed with Dacron patches. Reinvestigation 10 days after the operation revealed a residual pressure gradient across the outflow of the systemic ventricle of less than 10 mmHg. A secondary ventricular septal defect was detected in the anterior muscular septum at the same time and closed with a patch in a reintervention. At discharge from the hospital two weeks later the child was in excellent condition and had a stable sinus rhythm. The preoperative differential diagnosis of a double outlet right ventricle with L-malposition of the aorta as well as possible surgical approaches are discussed.     

彩色多普勒超声心动图诊断完全性大动脉转位

目的 探讨彩色多普勒超声早期诊断完全性大动脉转位的价值。方法 采用彩色超声检查完全性大动脉转位80例,按顺序分段法进行。结果 80例均显示主动脉在前,发自右心室,肺动脉在后,发自左心室,合并畸形包括VSD、ASD、PDA、PS等。其中2例手术病例及7例尸解病例与超声诊断相符。结论 超声心动图能准确诊断大动脉转位及伴随畸形,并提供部分血流动力学资料。     

Mitral atresia with premature closure of the oval foramen, right-sided levoatriocardinal vein and thrombus formation in the left atrium

We describe a 4-week-old baby with mitral atresia, hypoplastic left ventricle, ventricular septal defect, preductal coarctation and premature closure of the oval foramen whose only outlet from the left atrium was a stenosed right-sided levoatriocardinal vein and who in addition developed left atrial thrombi. Cross-sectional echocardiography was extremely helpful in establishing the diagnosis.     

Management of Inadvertent Left Ventricular Permanent Pacing

Inadvertent implantation of a pacemaker lead in the left ventricle is an uncommon complication. We report a case of a permanent pacemaker lead inadvertently placed through the left subclavian artery, across the aortic valve into the left ventricle. A chest X-ray one month after the procedure showed an unusual course of the lead and a 12-lead ECG and a transthoracic echocardiogram confirmed the diagnosis. The patient refused surgical removal and remained on full anticoagulation. No clinical events were recorded during a 3-year follow-up. In such cases we propose life-long full anticoagulation as an alternative to surgical lead extraction.     

Blunt Chest Trauma Resulting in Both Atrial and Ventricular Septal Defects

Cardiac septal defects are known complications to blunt chest trauma. The incidence of a traumatic isolated atrial septal defect is unknown and the concurrent occurrence of nonlethal ventricular and atrial septal defects has not been reported. A healthy male sustained violent blunt chest trauma resulting in traumatic cardiac septal disruption in the atrium and ventricle. The defects were detected by echocardiography within 14 hours of the accident. The extent of damage was confirmed at the time of surgical repair. The patient recovered uneventfully. The diagnosis and management of concurrent ASD and VSD is similar to single septal injury.     

Interaction Between Atrial Pacing Lead and Epicardial Ventricular Wire Resulting in Unintended Ventricular Capture by Pacemaker Atrial Output

A 65-year-old man with a history of coronary artery disease underwent coronary artery bypass grafting in 1997 and 1998. He also received a permanent dual chamber pacemaker implantation during the second bypass surgery for complete heart block. He presented a year later to our pacemaker clinic for follow-up. Initial ECG showed ventricular capture by pacemaker atrial output (bottom tracings, left side). When the atrial output was decreased by 0.5V, normal atrial and ventricular pacemaker function was restored (bottom tracings, right side). A chest X-ray revealed an active fixation atrial lead implanted to the right atrium and a passive fixation lead to the ventricle. There was no apparent insulation failure of either lead by X-ray or by impedance measurements. An epicardial pacing lead implanted during bypass surgery for temporary postoperative pacing was not completely removed. The proximity between the retained epicardial wire and the screw of the active fixation atrial lead (arrow) support the hypothesis that the atrial output was conducted by the retained epicardial wire into the ventricles, resulting in unintended ventricular capture by the atrial output. However, we could not exclude the possibility that the atrial lead directly resulted in ventricular capture due to its proximity to the AV grove.     

Non-invasive diagnosis in clinically suspected atrial septal defect of secundum or sinus venosus type. Value of combining chest x-ray,phonocardiography, and M-mode echocardiography.

Twenty-three consecutive patients with clinical (auscultatory and electrocardiographic) signs of uncomplicated atrial septal defect of secundum or sinus venosus type were examined by chest x-ray, phonocardiography, and echocardiography, before right heart catheterisation. Seventeen (74%) had atrial septal defect, two patients (9%) had insignificant pulmonary stenosis, and four subjects (17%) were normal. No false positive diagnosis of atrial septal defect was made by chest x-ray examination, whereas increased vascular markings were incorrectly interpreted as pulmonary congestion in one case. Four patients had x-ray films showing questionable signs of left-to-right shunt. Six of 15 patients with a large left-to-right shunt were correctly selected for surgery based on radiological findings. One false negative but no false positive diagnosis of atrial septal defect was made by phonocardiography. Four cases with and four cases without atrial septal defect were classified as having questionable phonocardiographic signs of atrial septal defect. Echocardiographic distinction between those with atrial septal defect and those without atrial septal defect was correct in all cases; quantitative measurement of left-to-right shunt, however, was unsatisfactory. Combined normal findings by x-ray film and echocardiography appeared adequate in all cases for the exclusion of atrial septal defect (six patients). When the six patients who were correctly identified for surgery from the radiological findings are included, there was a total of 12 patients out of 23 (52%:95% confidence limits 31 to 73%) who were evaluated definitively by the non-invasive tests.     

Double outlet left ventricle with intact ventricular septum: a cross-sectional and Doppler echocardiographic diagnosis.

Double outlet left ventricle with intact ventricular septum, valvar pulmonary stenosis, an atrial septal defect within the oval fossa, dysplastic tricuspid valve and normally related great arteries are described in a four-year old male child presenting with cyanosis since birth. The diagnosis was made by cross-sectional and Doppler echocardiography and confirmed by cineangiocardiography.     

Patent foramen ovale

INTRODUCTION: Intentional or unintentional placement of a pacemaker lead into the left ventricle is an uncommon clinical entity that is associated with a high risk for systemic embolization and enormous difficulties in case of explantation. Unintentional implantation through a patent foramen ovale via the mitral valve is the usual pathway for this malposition. METHODS: We report a case where a pacemaker lead was placed intentionally into the left ventricle via a patent foramen ovale for biventricular pacing for resynchronization therapy. Later, the patient developed life-threatening pacemaker lead-associated endocarditis with sepsis. Emergency open heart surgery for lead removal was necessary in the form of a reoperation after bypass graft surgery a number of years earlier. CONCLUSION: Although it is technically feasible to implant the pacemaker lead into the left ventricle via a patent foramen ovale, we consider this option to be obsolete for use with a biventricular pacemaker, due to the multitude of risks, which can, in part, be life-threatening for the patient.     

An Unusual Case of Embolic Stroke: A Permanent Ventricular Pacemaker Lead Entirely Within the Arterial System Documented by Transthoracic and Transesophageal Echocardiography

A pacemaker lead in the left ventricle is a rare complication of implantation. Recognition of this complication is important because thromboembolic events are associated. We report the first case, to our knowledge, of a patient who had a permanent pacemaker implanted via the left subclavian artery to the left ventricle, which is documented by electrocardiography, chest radiography, thoracic echocardiography, and transesophageal echocardiography.