Percutaneous permanent pacemaker implantation via the azygous vein in a patient with superior vena cava occlusion

Occlusion of the superior vena cava (SVCO) makes implantation of permanent pacemakers challenging and difficult. We describe an extended application of a Medtronic Attain (Medtronic Inc., Minneapolis, MN, USA) guide catheter (a tool designed for delivery of left ventricular pacing leads into the coronary sinus) for delivery of a right ventricular pacing lead via the azygous vein in a 72-year-old woman with SVCO secondary to long-term central venous hemodialysis catheters. This approach allowed the use of an endocardial pacing lead, implantation under local anesthesia, and conventional positioning of the pacemaker generator in the pectoral region in a patient with SVCO.     

Pacemaker-Induced Superior Vena Cava Syndrome: Report of Four Cases and Review of the Literature

Superior vena cava syndrome due to transvenous pacing leads is a rare event. We describe four cases. One occurred among 3,100 primary pacemaker insertions performed at our institution. In the other three cases the primary insertion had been performed elsewhere. Over 30 cases have been reported previously. Local infection, which preceded the development of superior vena cava syndrome in each of our four cases, and the presence of a severed retained lead, as in three of our cases, are important predisposing factors. There is no strong evidence that multiple lead insertion, if each lead remains intact, significantly increases the risk. The pathology at the site of obstruction includes thrombosis and in some cases fibrotic narrowing. Venous angiography is useful to show the site of obstruction, the extent of collateral circulation and to assess the response to treatment. Treatment should include removal of any infected pacemaker apparatus, anticoagulation and, if symptoms are of recent onset, thrombolytic therapy. Most patients improve but in those who do not angioplasty or surgical relief of the obstruction may be helpful.     

Superior vena cava stenting and transvenous pacemaker implantation (stent and pace) after the Mustard operation

Summary The Mustard operation for transposition of the great arteries is associated with good long-term survival. Typical complications at follow-up include progressive loss of sinus node function requiring permanent pacemaker implantation, and systemic venous pathway obstruction often precluding a transvenous approach to pacing. We report on 7 patients (median age 14.1; range 5–19) with bradyarrhythmia requiring permanent pacemaker implantation with associated stenosis (n = 6) or occlusion (n = 1) of the superior vena cava, in whom stent implantation relieved the obstruction and facilitated subsequent transvenous permanent pacing. In five of them stenting and pacemaker implantation were performed during a single procedure; two patients underwent elective pacemaker implantation 6 weeks later. In one patient the pacemaker had to be explanted due to pacemaker pocket infection. In the others the follow-up has been uneventful, with excellent chronic pacing thresholds and appropriate sensing. Two patients have had their generator replaced electively. We conclude that stenting of the SVC stenosis allows implantation of transvenous pacemaker leads with good intermediate term results in patients with a Mustard operation for transposition of the great arteries.     

Two-Dimensional and Doppler Echocardiographic Identification of Infrahepatic Interruption of Inferior Vena Cava with Azygos Continuation

Congenital anomalies of systemic venous return have been associated with pacemaker complications. Awareness of the existence of these anomalies prior to catheterization can lead to the utilization of an alternate route for pacing, avoiding undue delay in the institution of pacing which may be urgently needed. Pulse Doppler echocardiographic demonstration of turbulent flow in the azygos vein and superior vena cava combined with subcostal two-dimensional echocardiographic finding of a small channel opening into the right atrium appear to be highly specific findings in the diagnosis of infrahepatic interruption of inferior vena cava with azygos continuation.     

Early Complications After Dual Chamber Versus Single Chamber Pacemaker Implantation

This study was performed to compare the frequency of early complications after single chamber versus dual chamber permanent pacemaker implantation. Early complication was defined as one occurring in the 6-week period following implantation. We prospectively analyzed consecutive pacemaker implantation from January 1987 to June 1993 at our regional center. All complications were also analyzed for the relationship to operator experience, the venous access route, and the presence of temporary pacing wire at the time of implantation of the permanent pacing system. A total of 2019 new pacemaker units were implanted during this period. 1733 patients (85.8%) received a VVI pacemaker and 286 (14.2%) a DDD unit. Wound infection occurredin 11 (0.6%) VVI patients and 6 (2.1%) DDD patients. Lead displacement occurred in 18(1 %) VVI patients and 15 (5.2%) DDD patients (11 [3.8%] atrial and 4 [1.4 %] ventricular). There were 10 (0.6%)pneumothoraces, 9 (0.5%) hematomas requiring drainage, 1 (0.06%) chylocele, and 2 (0.1%) deaths in the VVI group. There were 2 (0.7%) pneumothoraces, 2 (0.7%) hematomas, and no deaths in the DDD group. There was no significant increase in complications for experienced infrequent implanters (< 12 systems per year). In both groups the subclavian approach was associated with a risk of pneumothorax when compared to the cephalic approach. The rate of wound infection was higher in patients who had a temporary pacing wire in place. The use of prophylactic antibiotics does not appear to affect the incidence of wound infection. The early complications in the DDD group were higher than in the VVI group (8.7% vs 2.9%, P < 0.05), being mainly due to an increased incidence of wound infection and atrial lead displacement.     

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

A patient underwent dual chamber pacemaker implantation by puncture of the left subclavian vein. During the procedure we observed persistence of the left superior vena cava. A "J-shaped" atrial lead was used for ventricular pacing with excellent long-term results. This technique can be a valuable alternative when confronted with the problem of persistent left superior vena cava during pacemaker implantation.     

A Multicenter Experience with a Bipolar Tined Polyurethane Ventricular Lead

A multicenter study was undertaken to determine the failure rate of a specific polyurethane bipolar tined pacing lead, the Medtronic 4012 pacing lead. Six centers in the United States and Canada implanted 1,190 Medtronic 4012 pacing leads. The study was designed to determine the probability and clinical manifestations of lead failure. Only failures compatible with an insulation problem were included. The probability of a 4012 lead failure by Kaplan-Meier analysis was 20.9% at 6 years after implantation. Failures were manifested as sensing abnormalities, failure to capture, early battery depletion, and significant decrease in measured impedance compared with the previous impedance measurements. Of the 95 definite lead failures, 16 (16.8%) were associated with symptoms similar to those experienced before pacemaker placement. The observed failure rate is unacceptable, and strong consideration should be given to replacing the 4012 pacing lead in pacemaker-dependent patients and closely monitoring nondependent patients.     

Transvenous Pacemaker Implantation Via a Unilateral Left Superior Vena Cava

A 72-year-old man with a unilateral left superior vena cava and anomalous drainage of the inferior vena cava required permanent pacing. The anomalies were verified by venography and cardiac catheterization. Difficulties in implantation of a temporary and permanent pacemaker are described. A transvenous endocardial lead was placed in a stable position in the right ventricle. The pacemaker system has now functioned normally for 32 months.     

Permanent Transfemoral Pacemaker Implantation Is the Technique of Choice for Patients in Whom the Superior Vena Cava Is Inaccessible

We describe transfemoral pacemaker implantation in three patients in whom pacing via the superior vena cava was not possible or suboptimal. The first was an 88-year-old man with superior vena cava obstruction presenting with fractured spicardial pacing leads. Recent pneumonia increased the risks of a general anesthetic. The second patient was a 57-year-old man who was intolerant of a pectorally sited pacemaker because of the thinness of his anterior chest wall. The third patient was a 69-year-old woman who presented with an infected eroding pectorally sited pacemaker. Scarring secondary to a previous pacemaker infection rendered the contralateral pectoral site inaccessible. Since the subclavian route was inaccessible (case 1) or suboptimai (case 2 and 3), we implanted transvenous pacemakers via the femoral route, which was safe, and effective, during a 6-month follow-up period.     

经永存左上腔静脉植入起搏电极导线的方法探讨

目的初步探讨经永存左上腔静脉植入起搏电极导线的方法。方法 4例永存左上腔静脉合并右上腔静脉缺如的缓慢性心律失常患者,经左上腔静脉植入右心房和右心室起搏电极导线,心房起搏电极固定于右心耳(4例),心室起搏电极分别固定至右心室间隔部(2例)或心尖部(2例)。术后当天、术后3个月及1年分别测试起搏电极参数。结果 4例患者均成功放置右心房(心耳处)和右心室(间隔部或心尖部)起搏电极导线,随访1年,起搏电极参数良好。结论经左上腔静脉植入起搏电极导线具有一定的挑战性,但通过适当的导丝塑形和操作,通常可将导线固定于右心房心耳部和右心室间隔部或心尖部。     

Permanent pacemaker therapy before and after the reunification of Germany: 16 years of experience at an East German regional pacing center

The reunification of Germany had a significant influence on the management of patients with bradyarrhythmias. The current study was performed in a regional pacing center located in the former German Democratic Republic. It compares the situation of patients with critical bradyarrhythmias before and after the reunification of Germany in 1990 focusing on (1) indication for pacemaker implantation, (2) pacemaker modalities and function, (3) type of leads, (4) frequency of reintervention, and (5) early and late complications. The study covers 9 years before and 7 years after the reunification. A total of 1,125 patients were included, and the database was formed by the patients' files and the protocols of implantation. The situation before reunification was characterized by a nonavailability of modern physiological pacing devices and insufficient diagnostic equipment. Between 1981 and 1990, 384 patients underwent pacemaker implantation solely receiving single chamber devices with no or only minimal feasibility of programming. Between 1990 and 1996, 741 patients were treated, and they all received modern pacemakers having the capability of multiprogramming and telemetry. Regarding complications of pacemaker therapy, lead related problems significantly decreased after the reunification (dislocation, 5.3% vs 1.7%, P < 0.05; exit block, 6.7% vs 1.4%, P < 0.05) opposite to pacemaker infections, which significantly increasing after dual chamber pacemakers were implanted (2.2% vs 6.0%, P < 0.05). The reunification of Germany dramatically improved the situation of patients with critical bradyarrhythmias leading to free access to high-tech pacing equipment within a few months. However, the abrupt change from antiquated to modern pacemaker therapy created some new problems, especially regarding application and handling of modern physiological pacing devices.     

Permanent Pacemaker Positioning Via the Inferior Vena Cava in a Case of Single Ventricle with Loss of Right Atrial-Vena Cava Continuity

Successful dual chamber pacing was achieved by implanting permanent pacemaker leads using an extra-peritoneal approach to the inferior vena cava in a 48-year-old patient with a single ventricle, transposition of the great vessels, and a right atrial pulmonary artery shunt (Glenn's procedure). The pacemaker generator was implanted into a subcutaneous pockel in the anterior abdominal wall.     

Congenital Absence of Superior Vena Cava: Unusual Anomaly of Superior Systemic Veins Complicating Pacemaker Placement

Congenital anomalies of the superior systemic veins can complicate placement of transvenous pacemaker electrode leads. Persistent left superior vena cava is the most common congenital anomaly; in this paper, we describe the case of a patient who had con-genital absence of both superior venae cavae, which has not been reported pre-viously. The superior syslemic veins drained into persistent double ozygos veins subdiaphragmatically. The anomaly was verified by venography. Temporory car-dioc pacing was established by passing the electrode lead through the femoral vein, and a permanent epicordial pacemaker lead was placed thereafter. This appears to be the first recorded case of such an anomaly.     

Extraction of an Intravascularized Pacemaker Lead—A New Approach to an Unusual Problem

A new catheter approach to removing an intravuacularized, nonfunctional pacemaker lead which was fixed at both distal (right ventricular endocardium) and proximal (brachiocephalic vein/superior vena cava) ends is described. This case also emphasizes the need for removal of an old pacemaker lead that caused bacteremia in a patient with a prosthetic aortic valve even when infection was presumed to be cured.     

Pacemaker-induced superior vena cava syndrome: clinical evaluation of long-term follow-up

BACKGROUND: Pacemaker-induced superior vena cava (SVC) syndrome is a rare but serious complication of permanent pacemaker implantation. Because of its rarity, little is known about the long-term prognoses of such patients. METHODS: Five patients, mean age 62 +/- 11.4 years, with pacemaker-induced SVC syndrome for more than 10 years were investigated. The clinical evaluation included: exercise testing, thrombophilia lab tests, and a chest CT. RESULTS: Two of the patients manifested complications of SVC syndrome which included thoracoabdominal subcutaneous collaterals. One of these patients simultaneously developed an increase in the pacing threshold which required the implantation of epicardial leads. Three of the five patients had normal age-adjusted VO(2) AT und VO(2) max. Four of the patients were both heterozygous for a polymorphism of PAI-1 and were homozygous for a polymorphism of t-PA. One of these patients also was heterozygous for a polymorphism of factor V and glycoprotein IIb/IIIa. The chest CTs revealed extensive and varying collateral circulation patterns in all of the patients. CONCLUSIONS: The development of pacemaker-induced SVC syndrome is the result of various predisposing factors including thrombophilia. Many patients retain normal age-adjusted cardiopulmonary capacity and demonstrate stable clinical findings on the long-term as the result of the development of extensive collateral vessel systems. The most serious complication was the combination of SVC syndrome and the simultaneous malfunctioning of one of the leads requiring implantation of a new lead.     

The Combined Transvenous Implantation of Cardioverter Defibrillators and Permanent Pacemakers

We developed criteria for implantation and programming of permanent endocardial pacemakers in patients with a nonthoracotomy ICD system. These criteria were prospectively used in 10 patients who recieved an ICD prior to (n = 5) or following (n = 5) implantation of a dual chamber (n = 6) or ventricular (n = 4) pacemaker with a unipolar (n = 4) or bipolar (n = 6) lead configuration. All patients were tested for interactions or malfunctions. Undersensing of ventricular fibrillation by the atrial sense amplifier and inadequate atrial pacing occurred in one patient with a unipolar dual chamber system programmed to AAIR but didn't impair ICD sensing. Transient or permanent loss of capture or sensing of the pacemaker was not observed after ICD shocks with the output programmed to double pulse width and voltage of stimulation threshold and the sensitivity to 50% of the detected R wave. One episode of transient reprogramming occurred without clinical consequences. One unipolar ventricular pacemaker lead had to be exchanged against a bipolar lead because of oversensing of the pacing artifact by the ICD. There was no failure of an ICD to detect ventricular arrhythmias due to inadequate pacemaker activity. During a follow-up period of 21 ± 11 months, a total of 78 ventricular arrhythmias were effectively treated in six patients. Thus, a combined use of transvenous ICD and pacemaker is possible despite the close vicinity of pacing and defibrillations leads. Optimized programming different to the common settings is required. As interactions occurred only in unipolar pacemaker leads bipolar systems should be used in these patients.     

A Comparison of VVIR and DDDR Pacing Following Cardiac Transplantation

We compared the clinical course of patients paced in VVIR versus DDDR mode to determine the most appropriate method of pacing following cardiac transplantation. Pacemaker implantation was required in 9 of 90 orthotopic cardiac transplants (10%). Indications included sinus bradycardia or sinus arrest (8 patients) and AV node dysfunction (1 patient). VVIR pacemakers were implanted in four patients and DDDR in five patients. DDDR patients : The mean P wave was 1.7 mV and the mean atrial stimulation threshold was 0.8 V (at 0.5 msec). During follow-up of 20 months, two atrial lead complications developed (29% of leads in 33% of patients). No lead complications were directly related to endomyocardial biopsy. VVIR patients : All four patients developed VA conduction with mean VA time 180 msec (160–240 msec). Two patients developed pacemaker syndrome. Conclusions : VA conduction and pacemaker syndrome may develop in cardiac transplant recipients paced in the VVIR mode. Dual chamber pacing is technically feasible and preferable following cardiac transplantation.     

Steroid-Eluting Epicardial Leads in Pediatrics: Improved Epicardial Thresholds in the First Year

From 1986 to 1991, we evaluated the clinical use of three new epicardial lead designs incorporating a steroid-eluting electrode. Medtronic models SP2114 (bipolar high profile), 10320 (bipolar low profile), 10295A/4965 (unipolar low profile) steroid epicardial (SE) leads were used on either atrium or ventricle for a total of 21 lead placements in 17 patients. Energy thresholds (T) were calculated and compared with our most recent 16 nonsteroid epicardial (NE) Medtronic model 4951 lead implants for which T was available. SE leads demonstrated no acute T rise and continued T improvements at 1 year of follow-up. We conclude that epicardial application of SE lead technology offers a major improvement in pacing lead function and potential pacemaker longevity over NE leads in pediatric patients in whom endocardial pacing is precluded by size or anatomy.     

Ancillary tools in pacemaker and defibrillator lead extraction using a novel lead removal system

A previous report described our preliminary experience with a highly successful pacing lead removal system (VasoExtor). Extending this experience, we found it necessary to use additional tools to enhance the success of percutaneous lead extraction with this system. In the present series, we used the standard locking stylets (S and K), and recently, one newer type of stylet (Magic) over the last 3 years in 34 patients to extract 48 pacemaker leads in 31 patients and 3 defibrillator (ICD) leads in 3 patients. Lead extraction was carried out in 23 men and 11 women (aged 64 +/- 17 years) because of pacemaker infection (n = 21), pacemaker (n = 8) or ICD (n = 3) lead malfunction, or prior to ICD implant (n = 2). Leads were in place for 3.5 +/- 3.7 years. Infections, involving pocket and lead(s), were due to S. epidermidis (n = 13), S. aureus (n = 6), S. aureus plus E. coli (n = 1), for fungi (n = 1). Of the 48 pacing leads, 31 were ventricular, 15 atrial, and 2 were VDD leads. The ICD leads were two double-coil leads (CPI) and one single-coil lead (Telectronics). Using the S (n = 12), K (n = 8), or Magic (n = 3) stylets, all pacing leads in 23 patients and the ICD leads in 2 patients were successfully removed from a subclavian approach using the locking stylets. However, in nine (26.5%) patients ancillary tools were required. In four patients, lead fragments were captured with use of a noose catheter, a pigtail catheter, and a bioptome from a right femoral approach. In two patients, locking could not be effected and a noose catheter from the right femoral vein was used, aided by a pigtail and an Amplatz catheter and a bioptome to remove three leads. In a patient with an ICD lead, a combined subclavian (stylet S) and right femoral approach (noose catheter) was required. In a patient with a dysfunctional ventricular lead 12 years old, a motor drive unit was used to facilitate the exchange of locking stylets, but extraction failed. In another patient, a fragment of a dysfunctional ventricular lead remained intravascularly despite resorting to a femoral approach. Finally, lead removal was completely (32/34, 94%) or partially (1/34, 3%) successful in 33 (97%) of 34 patients for 50 (98%) of 51 leads without complications. In conclusion, to enhance the success of pacing or ICD lead extraction with use of the VascoExtor locking stylets, an array of ancillary tools were required in more than one fourth of patients.