Recurrent postcardiac injury syndrome mimicking cardiac perforation following transvenous pacing: An unusual presentation

We report a case of recurrent postcardiac injury syndrome (PCIS) after pacemaker lead insertion. Each episode was attended by hemorrhagic pleuro-pericardial effusion with drop in hemoglobin levels leading us to consider cardiac perforation and subject the patient to surgical pericardiotomy. However, no perforation or active bleeding was detected on exploration. This unusual case illustrates the occurrence of PCIS following pacemaker lead insertion, mimicking cardiac perforation. This entity should be considered in patients who, after pacemaker lead insertion, develop pericardial and pleural effusion associated with markers of inflammation.     

Delayed cardiac tamponade after pacemaker insertion

Cardiogenic shock is one of the most dramatic presentations in Emergency Medicine and requires rapid and accurate assessment, evaluation, and treatment. The cardiovascular disasters that present with shock include acute myocardial infarction with pump failure, aortic dissection, massive pulmonary emboli, and cardiac tamponade. We report a patient who presented to our Emergency Department (ED) in cardiogenic shock 10 days after insertion of a permanent cardiac pacemaker. The patient had developed pericardial tamponade secondary to the insertion. In reviewing the literature, we found many reports relating to complications of pacemakers and even more information regarding the various etiologies of cardiac tamponade, but cardiac tamponade as a consequence of pacemaker insertion rarely has been reported. Cardiac tamponade can occur secondary to perforation of the right ventricle during pacemaker electrode insertion and manipulation. Perforation is generally believed to be benign and self-limiting and only rarely causes tamponade and hemodynamic compromise; however, that was not the case for our patient.     

Postpericardiotomy Syndrome and Cardiac Tamponade as a Late Complication After Pacemaker Implantation

SPINDLER, M., et al. : Postpericardiotomy Syndrome and Cardiac. Tamponade as a Late Complication After Pacemaker Implantation. In a 78-year old woman, pacemaker implantation was complicated by a transient perforation of the endocardial lead. The patient was in stable condition for up to 7 weeks after implantation, after which pericardial effusion and subacute cardiac tamponade developed and pericardiocentesis became necessary. This case illustrates that even after initially uneventful pacemaker lead perforation, careful, long-term follow-up is necessary to recognize the potential development of late postpericardiotomy syndrome.     

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.     

Right-sided Infective Endocarditis with Acquired Tricuspid Valve Stenosis Associated with Transvenous Pacemaker: A Case Report

Five years prior to presentation, a 29-year-old woman received a transvenous pacemaker (DDD) for sick sinus syndrome and nodo-hisian pathology. After pacemaker insertion, she complained of recurrent febrile episodes. Her pacemaker related endocarditis was quite unusual for the infecting organism (a micrococcus) and for an acquired tricuspid valve stenosis. The suspected cause was confirmed at surgery.     

Absence of device-device interaction (DDI) in a patient with cardiac and diaphragmatic pacemakers for congenital central hypoventilation syndrome

Autonomic control of ventilation is impaired in patients with Ondine's curse or congenital central hypoventilation syndrome (CCHS), but voluntary control remains intact. Bradyarrhythmias can be life threatening. In a patient with CCHS and long sinus pause requiring cardiac pacemaker insertion, a diaphragmatic pacemaker inserted in early childhood caused diaphragmatic pacer spikes observed during the interrogation of the cardiac pacemaker. Diaphragmatic pacing did not interfere with the cardiac pacemaker function.     

Malposition of A Transvenous Cardiac Electrode Associated with Amaurosis Fugax

A 55-year-old male received a transvenous ventricular pacemaker for sick sinus syndrome. After pacemaker insertion, he developed recurrent episodes of amaurosis fugax. The source of thromboemboli was the pacemaker electrode malpositioned in the left ventricle. Position of the electrode was diagnosed correctly by two-dimensional echocardiography. The malposifioned electrode was successfully removed with cessation of recurrent thromboembolic phenomenon.     

Cardiovascular abnormalities and arrhythmias in patients with Ondine's curse (congenital central hypoventilation) syndrome

Patients with congenital central hypoventilation syndrome (CCHS) (Ondine's curse syndrome) have impaired autonomic control of ventilation with intact voluntary control of respiration. Autonomic dysfunction and cardiac abnormalities are common in CCHS. Bradyarrhythmias are life-threatening and often require pacemaker insertion. We presented a case of a patient with CCHS suffering from long sinus pauses requiring cardiac pacemaker insertion. Patients with CCHS are at risk for pulmonary hypertension and cor pulmonale secondary to chronic hypoxia. Diaphragmatic pacing has been beneficial in some patients with CCHS. In this article, we review concomitant cardiac abnormalities and the occurrence of bradyarrhythmias in patients with CCHS.     

Pacemaker electrode perforation of the myocardium: an unusual etiology for recurrent abdominal pain

A 79-year-old man with a permanent pacemaker presented on five separate occasions to the emergency department with recurrent episodes of crampy abdominal pain. Extensive radiographic studies and repetitive labwork were nondiagnostic. Shortly after hospital admission on the fifth visit he experienced cardiac arrest and was successfully resuscitated. Poor pacemaker capture and paced clonic contractions of the diaphragm and abdominal wall were noted, suggesting myocardial perforation by the pacemaker electrode. A new lead and pulse generator were implanted and the patient was discharged without further abdominal discomfort. Implications of pacemaker electrode perforation of the myocardium are discussed.     

A case report of pacemaker lead perforation causing late pericardial effusion and subacute cardiac tamponade

Despite medical therapy, the overall prognosis for heart failure (HF) remains poor with high rates of sudden death and death from progressive HF. Device-based therapies offer considerable promise both for the relief of symptoms and for improving prognosis. Cardiac resynchronization therapy is a relatively new and effective treatment for patients with moderate to severe systolic HF and ventricular dyssynchrony. Clinical trials have demonstrated an improvement in quality of life, improved exercise tolerance, decreased HF hospitalizations, and improved survival. Complication rates for patients receiving cardiac pacemakers are relatively low. Although rare, cardiac tamponade caused by myocardial perforation during pacing lead insertion usually occurs a short time after the procedure. This case study discusses a patient who presented with cardiac tamponade 4 months after pacemaker implant. A small perforation of the right atrial lead caused a slow effusion into the pericardial sac. The patient's unusual presentation, hospital course, pathophysiology, and treatment for cardiac tamponade are discussed.     

Use of Radiofrequency Perforation for Lead Placement in Biventricular or Conventional Endocardial Pacing after Mustard or Senning Operations for D-Transposition of the Great Arteries

Background: Endocardial pacemaker lead placement can be challenging after Mustard and Senning operations for transposition of the great arteries (D-TGA), if there is atresia of the systemic venous pathways and because the coronary sinus cannot be used for cardiac resynchronization therapy. Radiofrequency (RF)-assisted perforation techniques have been used in congenital heart disease but have not been reported for use in pacemaker implantation.
Methods and Results: We describe RF perforation of an atretic superior systemic venous pathway and systemic venous baffles in three patients after Senning and Mustard operations to implant endocardial pacing systems to achieve conventional or biventricular pacing.
Conclusions: RF-energy-assisted perforation is feasible and effective tool to facilitate endocardial lead placement during dual-chamber and biventricular pacemaker implantation in patients with Mustard or Senning operations for D-TGA.     

Erosion of an Epicardial Pacemaker Secondary to Postpericardiotomy Syndrome

This report describes an unusual case of postpericardiotomy syndrome and pulse generator erosion following subxiphoid insertion of an epicardial pacemaker.     

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.     

Complications of Permanent Transvenous Cardiac Pacing: A 14-Year Review of all Transvenous Pacemakers Inserted at One Community Hospital

Five hundred and eighty-nine consecutive transvenous pacemakers implanted between January 1, 1971 and January 1, 1985 were reviewed. A complication incidence of 17% early in the study period (1971–1977) was caused by electrode displacement and perforation. As of 1975, smaller-sized electrodes with endocardial fixation were used and were associated with a significant decrease in this complication incidence to 2% by 1985. All other complications occurring during the entire study period (1971–1985) occurred at a frequency of 3% (20/589). Infection occurred in 3 of 589 cases; there were no extrusions or erosions. No mortality was attributed to pacemaker insertion. The "twiddler" syndrome seems to be increasing in frequency. Transvenous permanent pacing can be accomplished today with a low complication rate of 5% or less. The majority of these complications are minor and can be corrected easily. Our studies suggest that the reduced complication incidence is mainly related to improved technology.     

Pacemaker Syndrome Evaluated by Cardiopulmonary Exercise Testing

Two patients who presented with dyspnea on effort, persisting after insertion of a fixed rate ventricular demand pacemaker (VVI) for sick sinus syndrome, were evaluated by cardiopulmonary exercise testing. During VVI pacing a heightened ventilatory response to exercise and a fluctuation of ventilation occurred. The high ventilatory equivalent for CO2 throughout exercise with VVI pacing suggests that the patients had ventilation-perfusion mismatching due to an increase in the pulmonary capillary wedge pressure caused by 1:1 ventriculoatrial conduction. Rate responsive ventricular (VVIR) pacing associated with intact 1:1 ventriculoatrial conduction exaggerated the exertional dyspnea, while rate responsive atrial (AAIR) pacing improved the ventilatory response to exercise. We suggest that a heightened ventilatory response to exercise due to ventilation-perfusion mismatching may be an important factor causing the pacemaker syndrome, and that cardiopulmonary exercise testing is useful in identifying the exercise-induced symptoms with ventricular pacing.     

Delayed right ventricular lead perforation by a pacemaker lead 2‐year post‐implantation

Cardiac perforation by the lead of cardiac implantable electronic devices is a critical complication that often occurs within 24 h after the implantation but can occur later. We report a case of cardiac perforation of the right ventricular wall during the chronic period, 2 years after pacemaker implantation.     

Pneumopericardium With Cardiac Tamponade as a Complication of Cardiac Pacemaker Insertion One Year After Procedure

Background: Lead dislodgement has been shown to be the most common complication in the first 30 days after pacemaker insertion. Although it is rare, pneumopericardium with tamponade can also result. Objectives: We present a case of an extremely rare delay from cardiac pacemaker insertion to lead migration with resulting pneumopericardium and cardiac tamponade. Case Report: A 65-year-old woman with a past medical history significant for congestive heart failure, chronic obstructive pulmonary disease, and third-degree heart block, requiring pacemaker insertion 2 years prior with a revision 1 year prior, presented to the Emergency Department complaining of sudden-onset pleuritic chest pain. Her work-up revealed a pneumopericardium with atrial pacemaker lead migration into the right middle lobe of the lung. She suddenly developed hypotension and respiratory distress and required pericardiocentesis and, ultimately, surgical repair for a perforated right atrium. Conclusion: Pacemaker migration can lead to pneumopericardium and tamponade, even up to 1 year after placement.     

Elimination of Lead Dislodgement by the Use of Tined Transvenous Electrodes

Pacemaker lead dislodgement has accounted for a large proportion of the postoperative complications seen after transvenous pacemaker insertion. Ninety-two patients underwent implantation of a tined transvenous electrode over a three-year period without a single dislodgement. Excellent thresholds were obtained and no difficulties related to electrode insertion were encountered. Tined transvenous pacemaker leads are preferred for routine use at this time.     

Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: a 6-month follow-up prospective study

The incidence of venous lesions after permanent pacemaker insertion is around 45%. However, this incidence has been based on retrospective studies in a small series; moreover, factors predicting the development of these venous injuries have not been clearly defined. The aim of this study was to identify the risk factors for higher incidence of upper extremity deep vein thrombosis after transvenous permanent pacemaker insertion. The study included 229 patients and the criteria were age above 12 years and first permanent transvenous pacemaker implant. Exclusion criteria were pulmonary embolism, lower or upper extremity deep venous thrombosis, previous use of central venous catheters, coagulation disturbances, and malignancy. Age, race, sex, underlying cardiac disease, functional class to heart failure, LVEF, venous access, number, material and caliber of the leads, and previous use of a transvenous temporary pacemaker were considered. Six months after the pacemaker was implanted, 202 patients were submitted to digital subtraction venography ipsilateral to pacemaker implant. The venographies were normal in 73 (36%) patients and abnormal in 129 (64%) patients. Patients with previous use of transvenous temporary leads (P = 0,0001, OR = 4,260, confidence limits = 2,133-8,465) and LVEF < or = 40% (P = 0,0378, OR = 3,437, confidence limits = 1,064-12,326), had higher incidence of venous lesions. Previous use of a temporary pacemaker and LVEF < or = 0.40 were considered independent risk factors to a higher incidence of venous stenosis or thrombosis 6 months after permanent pacemaker insertion.     

Natural History of Severe Sinus Bradycardia Discovered by 24 Hour Holter Monitoring

This study follows patients with severe sinus bradycardia (40 beats per minute for 6 seconds or greater) in order to evaluate mortality and the effectiveness of permanent pacemaker insertion. Severe sinus bradycardia was noted on a 24-hour Holter in 95 patients. There were 64 males and 31 females with a mean age of 69 +/- 10 years. All were available for follow-up at 26 +/- 13 months. Twenty-eight required a permanent pacemaker at an average of 2 +/- 3 months after the Holter. Of this group 12 had the Holter for arrhythmia, 11 for cerebral symptoms, 4 for palpitations and 1 for chest pain. Only 1 was taking digitalis and no patients were taking Inderal. Six (21%) died at a mean interval of 21 +/- 15 months following pacemaker insertion. Sixty-seven did not require pacemaker insertion. The indications for Holter monitoring were arrhythmia in 16, palpitations in 19, cerebral symptoms in 20 and chest pain in 12. Four of these patients were on digitalis, 8 on Inderal, and 4 on both. Eleven (16%) died at a mean interval of 12 +/- 7 months after the initial Holter recording. Dizziness and/or syncope reoccurred in 22. Five had these symptoms even after pacemaker insertion. We conclude that severe sinus bradycardia is associated with a significant mortality. Insertion of a permanent pacemaker may decrease recurrent symptoms and slightly increase time of survival, but does not appear to influence the overall survival rate.