Infections in Transvenous Cardiac Pacemakers: Two More Cases

Two patients with metastatic pacemaker infections, one caused by Pseudomonas aeruginosa, 5 months after implantation, and the second by Streptococcus pneumoniae, 8 years after implantation, were treated successfully by removal of the pacemaker systems. Infection reoccurred in the patient with Pseudomonas aeruginosa, who initially underwent partial pacing system removal allowing the atrial lead to remain. Repeat partial atrial lead removal and contralateral pacemaker implantation was followed by clinical infection, which was resolved when both the implanted atrial lead fragment and the recently implanted pacemaker were both removed. Removal of all hardware is required for cure of pacemaker infection.     

起搏器安装术后患者局部沙袋加压的疗效观察

目的 为进一步探讨沙袋压迫对防止安装起搏器术后囊代出血的价值。方法 将１９８９年９月￣１９９３年１１月安装起搏器的５４例患术后局部加压沙代为对照组,１９９３年１２月￣２０００年１月安装起搏器的８４例患为观察组,术后囊代局部不用沙袋压迫。结果 对照组并发囊袋出血３例,囊袋皮肤坏死１例;观察组无１例囊袋出血和皮肤坏死。结论 提示起搏器安装术后局部用沙袋压迫不一定能防止术后囊袋出血,只要术中止血彻底     

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.     

The incidence and risk factors for venous obstruction after implantation of transvenous pacing leads

Several investigators have shown that the incidence of venous obstruction after pacemaker implantation was observed in 31-50% of pacemaker patients. However, these previous reports did not investigate the venous system prior to implantation. The aim of this study was to determine the incidence and risk factors for venous obstruction in patients with transvenous pacing leads. The study included 131 consecutive patients (64 men, 67 women; mean age 71.3 +/- 9.8 years) who were investigated using intravenous digital subtraction angiography (DSA) before and after permanent pacemaker implantation. Follow-up DSA was performed for a mean interval of 44 +/- 6 months after pacemaker lead implantation in 79 of 131 patients. A diameter narrowing > 60% was defined as an obstruction. Prior to implantation of pacing leads, venous obstruction was present in 18 (13.7%) of 131 patients. In 15 of these 18 patients, the obstruction was present at the site of the left innominate vein. Follow-up DSA, after implantation of pacing leads, showed that venous obstruction was observed in 26 (32.9%) of 79 patients. There were no significant differences between obstruction and nonobstruction groups in terms of age, sex, cardiothoracic ratio, left atrial dimension, left ventricular ejection fraction, baseline heart diseases for indication of pacemaker implantation, or number and body size of pacing leads. Neither clinical symptoms nor abnormal physical findings were observed in any patients. In conclusion, the incidence of venous obstruction after pacing lead implantation is less than that of previous reports, which might be related to the incidence of venous obstruction before pacing leads implantation.     

Microdislodgment of ventricular pacing lead undetectable during rapid pacing one year after implantation

A 71-year-old woman had undergone valvular heart surgery in 1981, and implantation of a permanent ventricular pacemaker for ventricular pauses during atrial fibrillation in 2001. One year after pacemaker implantation, she complained of faintness. When pacing at 100 beats/min the pacemaker functioned properly. However, pacing and sensing failure was detected at a pacing rate of 60 beats/min. At rapid pacing rates, the lead tip was in closer contact with the endocardium, and its microdislodgment was undetectable. The symptoms have resolved since the lead was repositioned.     

Unusual Approach of a Pacemaker Electrode in a Patient with a Silent Superior Vena Cava Syndrome

A man with a history of bilateral pectoral pocket infection and subsequent pacemaker implantation with a screw-in epicardial lead was referred because of increasing lead impedance. Venography revealed bilateral total occlusion of the subclavian and innominate veins with extensive collateral formation in this asymptomatic patient. Both internal jugular veins were also totally occluded. Because repeated pacemaker implantation using epicardial leads resulted in increasing lead impedance of the ventricular lead within 1 year after implant, an alternative approach was found using the superior caval vein with minimal invasive thoracotomy for single lead VDD pacing.     

Preliminary results with the simultaneous use of implantable cardioverter defibrillators and permanent biventricular pacemakers: implications for device interaction and development

We report our preliminary experience with the combined use of implantable cardioverter defibrillators (ICD) and biventricular pacemakers in six patients with heart failure and malignant ventricular arrhythmia. Two patients underwent ICD implantation for malignant ventricular arrhythmia after previous biventricular pacemaker implantation. One patient underwent biventricular pacemaker insertion for NYHA Class III heart failure after previous ICD implantation. Two patients underwent single device implantation. In the sixth patient, a combined implantation failed due to an inability to obtain a satisfactory left ventricular pacemaker lead position. The potential for device interaction was explored during implantation. In two patients a potentially serious interaction was discovered. Subsequent alterations in device configuration and programming prevented these interactions with long-term use. No complication of combined device use has been demonstrated during a mean follow-up of 2 months (range 1-4 months). Satisfactory ICD and pacemaker function has also been demonstrated. We conclude that combined device implantation may be feasible with currently available pacing technology and that further prospective studies are required in this area.     

早期下床对主动固定电极起搏器术后并发症的影响

目的 探讨主动固定电极起搏器植入术后6h下床活动的安全性及可行性。方法 将符合条件的228例起搏器植入术患者按手术单双日分为观察组和对照组,两组患者植入起搏器术后均给予常规护理,对照组患者按传统方法术后卧床24h;观察组患者术后平卧6h后在护士的指导、协助下,下床活动。结果 患者电极脱位、囊袋血肿、伤口出血的发生率两组无统计学差异（P〉0.05）;观察组患者腰背酸痛的程度较对照组患者轻（P〈0.05）,排尿、排便困难,尿潴留的发生率低于对照组（P〈0.05）。结论 主动固定电极起搏器植入术后6h下床活动是安全可行的,能减少卧床相关并发症,提高患者舒适度。     

Transarterial Permanent Pacing of the Left Ventricle

Clinical evaluation of a 64-year-old male patient with a permanent pacemaker showed a right bundle branch block in his ECG that led to the suspicion of catheter misplacement. A two-dimensional echocardiogram and bilateral venogram demonstrated that the pacemaker lead was not in the venous system and that its course was from the axillary artery to the left ventricle passing through the aortic valve. Thirty-three days after implant, replacement of the pacemaker lead through the venous system to stimulate the right ventricular endocardium was performed. At 7 month follow-up the patient has had no complication from his previous arterial pacemaker implantation.     

Long-term complication rates in ventricular, single lead VDD, and dual chamber pacing

A higher incidence of pacemaker related complications has been reported in DDD systems as compared to VVI devices. The implantation of single lead VDD pacemakers might reduce the complication rate of physiological pacing in patients with AV block. In a retrospective study, the data records of 1,214 consecutive patients with pacemaker implantation for AV block between 1990 and 2001 (VVI 36.5%, DDD 32.9%, VDD 30.6%) were analyzed. Complications requiring surgical interventions were compared during a follow-up period of 64 +/- 31 months. Operation and fluoroscopic times were longer in DDD pacemaker implantation compared to VDD and VVI devices:58 +/- 23 versus 39 +/- 10 and 37 +/- 13 minutes (P<0.001), 9.2 +/- 5.2 versus 4.1 +/- 2.4 and 3.5 +/- 2.3 minutes, respectively. Differences remained significant after correction for covariates. In a multivariate Cox regression model, the corrected complication hazard of a DDD pacemaker implantation was increased by 3.9 (1.4-11.3) compared to VVI and increased by 2.3 (1.1-4.5) compared to VDD pacing. Higher complication rates in DDD pacing were mainly due to a higher incidence of early reoperation for atrial lead dysfunction, whereas the long-term complication rate was not different from VDD or VVI pacing. Early and long-term complication rates did not differ between VDD and VVI pacemaker systems. In conclusion, operation time and complication rates of physiological pacing are reduced by VDD pacemaker implantation achieving values comparable to VVI pacing. Thus, single lead VDD pacing can be recommended for patients with AV block.     

心脏起搏器植入术后并发局部慢性溃疡伴感染的综合处理

目的 探讨起搏器植入术后并发局部慢性溃疡伴感染的综合治疗方法.方法2 005年1月-2010年5月,收治4例心脏起搏器植入术后并发局部慢性溃疡伴感染的患者.男3例,女1例;年龄3～79岁.心脏起搏器植入术后囊袋感染致皮肤破溃伴慢性溃疡2例,起搏器植入后局部张力过高所致局部慢性溃疡2例,其中2例患有2型糖尿病.所有患者均...     

Initial results with left ventricular pacemaker lead implantation using a preformed "peel-away" guiding sheath and "side-wire" left ventricular pacing lead

We report our preliminary experience with the use of preformed "peel-away" guiding sheaths and "side-wire" pacing leads for permanent biventricular pacemaker insertion in 13 patients with heart failure. Three of these patients were undergoing an upgrade of a preexistent VVIR pacing system after prior His ablation for medically refractory atrial fibrillation. Six of the patients had undergone attempted biventricular pacemaker insertion, but required left ventricular lead repositioning after total implantation failure or late displacement of the lead. The remaining patients were undergoing new system implantation. Target vessel cannulation was achieved in all patients. However, in one patient, diaphragmatic pacing throughout the target vessel length prevented successful implantation. All other implants were ultimately successful (92% success rate). We conclude that device implantation using a preformed sheath and side-wire pacing lead is feasible and may offer significant benefits over implantation with currently available technology.     

Delayed complications following pacemaker implantation

Acute complications resulting from permanent pacemaker implantation are well known and include perforation of the right atrium or right ventricle. Recently, several reports have described the occurrence of perforation and pericarditis as late complications following pacemaker implantation. These complications may occur days to weeks following uncomplicated pacemaker implantation and may lead to death if they are not recognized early. Five patients with late complications caused by active-fixation leads are reported and the clinical features of their presentation and management are reviewed. Late perforation of the right atrium or right ventricle is an uncommon complication after pacemaker implantation but should be suspected by the general cardiologist in a patient who has a device implanted within a week to several months prior to the development of chest pain.     

An approach to ablate and pace:AV junction ablation and pacemaker implantation performed concurrently from the same venous access site

BACKGROUND: Atrioventricular junction (AVJ) ablation combined with permanent pacemaker implantation (the "ablate and pace" approach) remains an acceptable alternative treatment strategy for symptomatic, drug-refractory atrial fibrillation (AF) with rapid ventricular response. This case series describes the feasibility and safety of catheter ablation of the AVJ via a superior vena caval approach performed during concurrent dual-chamber pacemaker implantation. METHODS: A total of 17 consecutive patients with symptomatic, drug-refractory, paroxysmal AF underwent combined AVJ ablation and dual-chamber pacemaker implantation procedure using a left axillary venous approach. Two separate introducer sheaths were placed into the axillary vein. The first sheath was used for implantation of the pacemaker ventricular lead, which was then connected to the pulse generator. Subsequently, a standard ablation catheter was introduced through the second axillary venous sheath and used for radiofrequency (RF) ablation of the AVJ. After successful ablation, the catheter was withdrawn and the pacemaker atrial lead was advanced through that same sheath and implanted in the right atrium. RESULTS: Catheter ablation of the AVJ was successfully achieved in all patients. The median number of RF applications required to achieve complete AV block was three (range 1-10). In one patient, AV conduction recovered within the first hour after completion of the procedure, and AVJ ablation was then performed using the conventional femoral venous approach. There were no procedural complications. CONCLUSION: Catheter ablation of the AVJ can be performed successfully and safely via a superior vena caval approach in patients undergoing concurrent dual-chamber pacemaker implantation.     

Oversensing from Electrode ''Chatter'' in a Bipolar Pacing Lead: A Case Report

An 81-year-old man was treated for high degree AV block and syncope with an AV universal (DDD) pacemaker. Bipolar active fixation atrial and ventricular leads were used. Intermittent oversensing from the ventricular lead was detected on Holter monitoring following implantation. This resulted in inappropriate inhibition of ventricular pacing. Ventricular electrogram showed spurious signals between 5 mV and 15 mV in magnitude coincident with ventricular lead inhibition. Treatment consisted of reprogramming the device to the VVT mode. Six weeks after implantation normal pacemaker function in the DDD mode was demonstrated on Holter monitoring and inappropriate pacer inhibition could not be demonstrated. We postulate that electrode 'chatter' between the cathodal ring electrode and the helix of the ventricular lead resulted in artifactual potentials sufficient to inhibit pacing. We hypothesize that fibrosis and fixation of the ventricular lead tip over a period of weeks eliminated these electromechanical artifacts and resulted in the oversensing problem being self-limited. Physicians should be aware of electrode 'chatter' as a cause of pacemaker oversensing.     

Pulsed Doppler echocardiographic detection of the origin of musical murmurs in a case of pacemaker implantation

We report a case of systolic and diastolic musical murmurs that developed 4 years after DDD pacemaker implantation. Echocardiographic examination disclosed no evidence of serious pacemaker-related complications. Pulsed Doppler examination with a sample volume at the right ventricular portion of a pacemaker lead showed prominent harmonic signals. The timing of the signals was consistent with that of musical murmurs. We considered vibration of the pacemaker lead as a possible origin of the musical murmurs. Systolic and diastolic musical murmurs can develop without serious cause in a patient with a transvenous pacemaker. Pulsed Doppler examination was useful in detecting the origin of musical murmurs.     

Implantation of Dual Chamber Pacemaker in a Patient with Persistent Left Superior Vena Cava

A 35-year-old patient underwent permanent pacemaker implantation because of symptomatic sinus bradycardia. During the procedure, persistent left superior vena cava was found. The ventricular lead crossed the tricuspid valve only after curving the stylet to form a loop in the right atrium (RA); subsequently, the curved stylet was changed to a straight one and the lead was positioned and screwed into the right ventricular apex. The atrial lead positioning was possible when the stylet was slightly curved and the lead could reach the anterior wall of the RA. At 18 months, a follow-up revealed normal pacemaker function and stable lead position.     

Results from the Use of a Preshaped Lead for Single-Pass VDD/DDD Stimulation

Main criticisms about single-pass VDD stimulation in patients with AV block and normal sinus node function concern atrial undersensing in a lead with floating atrial electrodes, and loss of AV synchrony if sinus node dysfunction develops after implantation. We evaluated the concept of a preshaped single-pass lead designed to place the atrial ring electrodes in a constant position close to, or in contact with, the atrial wall. A preshaped lead (Model 2775, Medtronic Inc.) was implanted in 14 patients and followed for up to 2 years. Mean P wave amplitudes (PWAs) were 3.1 mV at implantation, 1.2 mV at predischarge, and 1.3 mV after 12 months. In all patients, minimal PWAs were well above maximal atrial sensitivity of the pacemaker in all body positions during the complete follow-up; atrial undersensing was not observed. Effective atrial stimulation was possible in all patients at implantation (mean stimulation threshold 2.5 V at 0.50 ms), in 11 patients on the first day after implant (mean stimulation threshold 0.22 ms at 5.0 V), in 10 patients after 1 month (mean stimulation threshold 0.57 ms at 5.0 V), and in 10 patients after 1 year (mean stimulation threshold 0.65 ms at 5.0 V). Intermittent phrenic nerve stimulation could be provoked in six patients. In conclusion, the concept of a preshaped single-pass lead facilitated implantation, improved atrial sensing performance, and allowed atrial stimulation in some patients. Still, further improvements are necessary to decrease the atrial stimulation thresholds to acceptable values in all patients.     

Entrapment of pacemaker lead by a large netlike Eustachian valve within the right atrium

Summary During pacemaker implantation in a patient with permanent atrial fibrillation, it remained impossible to advance a passive fixation lead with fins through the right atrium. However, a lead with a retractable screw easily passed the right atrium and was positioned in the right ventricle. Transesophageal echocardiography revealed an extensive net–like perforated Eustachian valve within the right atrium that had caused entrapment of the anchor fins during lead implantation. Remnants of embryonal structures within the right atrium should be considered a rare possible barrier during pacemaker implantation.     

Tricuspid stenosis: a rare complication of pacemaker-related endocarditis.

We report a case of recurrent pacemaker lead endocarditis as the cause of acquired tricuspid stenosis. The diagnosis was made noninvasively by 2-dimensional Doppler echocardiography. The case was further complicated by a paradoxical septic embolism through a patent foramen ovale. This cascade of rear events after a pacemaker implantation has never been described in the literature before.