Cardiac strangulation from epicardial pacemaker leads: diagnosis, treatment, and prevention

Current Device Needs for Patients with Pediatric and Congenital Heart Disease

Pediatric electrophysiologists believe that there is a paucity of pediatric-specific cardiac implantable electronic devices (CIEDs) available for their patients. Specific patient characteristics such as vascular size, intracardiac anatomy, and expected somatic growth limit the types of CIED implants possible for pediatric and congenital heart disease (CHD) patients. These patients demonstrate higher CIED-related complication rates compared with adults. As the number of pediatric and CHD patients who require CIEDs increases, so does the need for advocacy. Fortunately, collaboration among the Food and Drug Administration, industry, and pediatric societies has led to the improvement of regulations and support for clinical trials.

A case of cardiac strangulation following epicardial pacemaker implantation in an adult: a case report

Background

Cardiac strangulation (CS) is a rare but potentially devastating complication caused by the leads of an epicardial pacemaker (EP). Most cases have been reported in paediatric patients, and there has been no report wherein the diagnosis was made in a living, adult patient, and treated successfully.

Case summary

A 31-year-old woman with a history of atrial septal defect (ASD) patch closure and EP implantation for congenital atrial stand-still presented with dyspnoea on exertion. The blood investigation of the patient showed liver dysfunction, chest radiography showed pulmonary artery dilatation, and transthoracic echocardiography showed right chambers dysfunction. Right heart catheterization showed haemodynamics similar to those of constrictive pericarditis, eventually leading to the diagnosis of CS due to EP leads. The patient was successfully operated upon.

Discussion

We reported the first case where CS was diagnosed in adulthood and successfully treated with surgical intervention. Cardiac strangulation is challenging to diagnose because of the small number of cases reported and the lack of definitive diagnostic algorithms or criteria. Surgical EP lead removal should be performed without hesitation in cases where CS is considered the primary aetiology of critical symptoms or complications because surgical removal is the only fundamental treatment for CS. In addition, paediatric patients undergoing EP implantation need for close follow-up.

Completely epicardial implantable cardioverter/defibrillator (ICD) and CRT-D systems: A case series and systematic literature review

BACKGROUND

Epicardial ICD systems and CRT-Ds using high voltage coils represent an alternative to transvenous systems in patients without central venous access and prior device complications including infection.

OBJECTIVE

We present a case series in the adult population of epicardial ICD/CRTD systems using high voltage epicardial coils. We summarize the existing data regarding techniques, efficacy, and safety.

METHODS

A retrospective board approved medical record review was conducted for all patients undergoing epicardial ICD/CRTD placement at our institution between January 2010 and May 2020. The literature was reviewed for prior published trials, case reports, and case series of epicardial high voltage coil insertions.

RESULTS

Eleven patients (six female, mean age 48 years) underwent epicardial ICD/CRTD implant including 5/11 completely epicardial CRTD systems. The procedure was performed via median sternotomy in eight patients, left anterior thoracotomy in two patients, and sub-xiphoid approach in one patient. After a mean follow up of 35 months, appropriate successful shocks were delivered in two (18%) patients and no patients received an inappropriate shock. Three of five (60%) patients had volumetric remodeling with CRT with significant improvement of LV EF. Device-related complications requiring a surgical/percutaneous revision or another DFT test occurred in six patients (54%). One patient died during follow up due to refractory heart failure. No cases of epicardial device infection, coronary artery compression, constrictive pericarditis, or erosion of defibrillator coils into intrathoracic organs were reported. No randomized studies comparing safety and efficacy of traditional transvenous or subcutaneous ICD systems and epicardial ICD systems using contemporary high voltage coils were found nor any studies directly comparing epicardial defibrillator patches versus epicardial coils. Thirteen case series and 24 single case reports published between 2004 and 2020 were identified describing in total a heterogenous group of 188 patients with ICD systems incorporating one or more epi- or pericardially positioned shock coils.

CONCLUSION

The use of epicardial defibrillation coils for ICD/CRT-D is a feasible treatment option for patients with either failed or contraindicated transvenous ICD systems. Dedicated epicardial high voltage leads with integrated pace-sense electrodes and specialized delivery tools for minimal invasive implantations may improve longer term outcomes.

Sudden cardiac arrest in an epicardial paced-dependent child: watch out, it's a pitfall!

Coronary artery compression by epicardial leads is a rare complication in children and can be difficult to identify with potentially lethal outcomes. Herein, we report the case of a previously asymptomatic paced-dependant 5-year-old girl who presented to our institution with resuscitated cardiac arrest. We describe the atypical sequence of clinical findings misleading initial diagnosis. Hardware failure and the commonly occurring lead fracture were incriminated in the mechanism of cardiac arrest, precipitating implantation of a new pacing system while concealing dynamic compression of the left anterior descending coronary artery.

Cardiac strangulation after epicardial pacing: the importance of non-specific symptoms and a low index of suspicion

Cardiac strangulation is a rare and potentially deadly complication of epicardial pacemaker implantation. A young boy presenting with chest pain and tiredness almost 7 years after pacemaker implantation was found to have cardiac strangulation. Literature review revealed 22 cases reported to date with a worrying rise in the number of reports over the past 3 years. Strangulation is associated with implantation of leads at a young age and appears to be related to somatic growth. Serial assessment with chest X-ray and echocardiogram is recommended, at least until full adult growth is attained with further coronary artery imaging reserved for symptoms or suspicious echocardiographic findings. If cardiac strangulation is diagnosed prompt replacement of the offending system is needed.

Sub-clinical myocardial ischaemia due to cardiac strangulation by an epicardial pacemaker lead

We present the case of a 10-year-old boy with congenital complete atrioventricular block who had cardiac strangulation by an epicardial pacemaker lead placed during infancy. Coronary angiography and Tc99m tetrofosmin myocardial perfusion scintigraphy suggested sub-clinical myocardial ischaemia.

Cardiac strangulation: An atypical complication from epicardial pacemaker leads in a newborn

We report a rare and serious complication of cardiac strangulation arising from the implantation of epicardial pacing leads in a newborn. Patient's follow-up 9-month postsurgery revealed compression under the pulmonary valve annulus by a pacemaker lead, causing progressive stenosis of the right ventricular outflow tract. The epicardial leads were replaced to relieve compression, and stenosis of the right ventricular outflow tract was rectified. Pacemaker implantation in newborns is not without challenges; epicardial leads should be carefully positioned to avoid any compression of cardiac structures.