Unusual complications of endocardial pacing

Tricuspid stenosis: An emerging disease in cardiac implantable electronic devices era. Case report and literature review

Tricuspid valve dysfunction and in particular tricuspid stenosis has recently been described secondary to cardiac implantable electronic devices. The valve is subjected to different mechanisms of injury related to the endocardial lead passing through its plane. The lead can form a loop or perforate one of the leaflets and initiate inflammatory response and fibrotic changes. Multimodality cardiac imaging is required to diagnose this clinical entity and decide on the best treatment plan. Here we present a case of a young female who developed tricuspid stenosis secondary to permanent pacemaker lead that was implanted 24 years before. We performed a review for all cases reported in the literature with a similar condition and various treatment approaches. <Learning objectives: 1. Tricuspid valve dysfunction can develop secondary to cardiac implantable electronic devices. Tricuspid regurgitation is the most common valve lesion however, tricuspid stenosis is reported as well. 2. Endocardial leads can cause injury to the valve initiating a cascade of inflammatory response and fibrosis. 3. Trans-thoracic echocardiography is the initial diagnostic modality but visualization of lead injury requires further cardiac imaging such as cardiac computed tomography and trans-esophageal echocardiography. 4. Various treatment modalities are reported in the literature; medical therapy, percutaneous valvoplasty; and surgery.>.

[Heart failure provoked by a pacemaker lead-induced tricuspid stenosis]

Tricuspid stenosis (TS) is an uncommon complication of ventricular pacemaker implantation. Mechanisms described by the literature are ventricular inflow obstruction by tricuspid vegetations (endocarditis) or multiple pacemaker leads and fibrosis secondary to mechanical trauma, accounting for perforation or laceration of the TV leaflets, or adherence between redundant loops and valve tissue. We present the case of iatrogenic tricuspid stenosis, observed in a 77-year-old man. Extrinsic tricuspid valve stenosis was detected by transthoracic echocardiography. Further investigations confirmed the intramyocardial lead position. Tricuspid valve stenosis due to transvenous leads are reported to be treated by surgical replacement, surgical valvuloplasty, or percutaneous balloon valvuloplasty.

High traffic congestion in right atrium

A 62-year lady presented with limb swelling and heart failure due to leads induced venous fibrosis and severe tricuspid stenosis, 33 years after pacemaker implantation. After undergoing surgical removal of all leads and tricuspid valve replacement under cardiopulmonary bypass, she regained a normal functional status and tricuspid and right ventricular functions.

Internal jugular vein thrombosis secondary to a permanent cardiac pacemaker: an unusual case of lateral neck swelling

OBJECTIVE

To describe an unusual case of lateral neck swelling in a patient with a permanent cardiac pacemaker.

CASE REPORT

We describe a patient who presented with a painful, lateral neck swelling due to an internal jugular vein thrombus. This thrombus originated from around pacemaker wires in the subclavian vein. This case is unusual, as the vast majority of thromboses in patients with cardiac pacemakers are found in the subclavian vein alone. We also review the literature on the relationship between cardiac pacemakers and internal jugular vein thrombosis, and on the management of the latter.

CONCLUSION

Our patient illustrates a rare cause of a painful, lateral neck swelling: an internal jugular vein thrombus secondary to a cardiac pacemaker. Clinicians should be wary of such pathology in similar patients, in order to ensure early treatment and avoidance of complications.

Complications of Pacemakers and Defibrillators in the Elderly

Within the United States, the elderly population is projected to increase 126% by 2050, making those over the age of 65 the most rapidly growing segment in the population. Permanent pacemakers and defibrillators are important therapies with expanding indications for their use, and older persons constitute the majority of recipients of these devices. Recognizing complications associated with these cardiac devices is essential in caring for patients with them. Complications can be related to the implantation procedure and are most commonly lead dislodgement, pneumothorax, lead perforation, hematoma, and infection. Intrinsic device programming can also result in complications such as pacemaker syndrome, pacemaker-mediated tachycardia, and inappropriate shocks. Extrinsic factors, such as electromagnetic interference and physically manipulating the device, can also result in problems. Recent work suggests that older age, by itself, is not associated with a significant increase in the complication rates from these devices and should not preclude their use.

Subtotal Innominate Vein Occlusion After Unsuccessful Pacemaker Implantation for Resynchronization Therapy

Cardiac resynchronization therapy is increasingly used to treat patients with poor left ventricular function and asynchronous left ventricular contraction. Generally, a transvenous approach is used for implantation of pacing leads. However, coronary sinus lead implantation may be associated with various problems that may result in abandoning of the procedure. In this report a patient is described with subtotal innominate vein occlusion after such a procedure who underwent video-assisted thoracoscopic surgery (VATS) for implantation of epicardial left ventricular pacemaker leads for resynchronization therapy.

[Tricuspid stenosis after pacemaker implantation without evidence of bacterial endocarditis. A case report]

Tricuspid stenosis related to endocardial pacemaker leads is uncommon. We report the case of a patient with severe tricuspid stenosis documented 15 years after the implantation of a permanent DDD pacemaker for symptomatic congenital heart block. The atrial and ventricular leads both had a loop at the level of the tricuspid valve that may have caused endothelial damage and, eventually, tricuspid stenosis.

Permanent cardiac pacemakers: issues relevant to the emergency physician, Part I

Many people benefit from the implantation of cardiac pacemakers for management of certain cardiac dysrhythmias. These patients are seen regularly in the emergency department with a variety of pacemaker complications and malfunctions. The presence of a pacemaker may also affect management of unrelated medical problems. This two-part series reviews the medical issues related to patients with permanent pacemakers. Part I covers pacing modes and terminology, complications of the implant procedure, and the approach to a patient with a permanent pacemaker. Part II covers the causes, diagnosis and management of pacemaker malfunction; the pacemaker syndrome; the pacemaker Twiddler's syndrome; and other considerations in the paced patient including diagnosis of acute myocardial infarction, ACLS protocols, trauma, and sources of interference. Indications for permanent pacemaker implantation and temporary external pacing will not be covered.

Acute and chronic phase platelet aggregability studies in Chinese patients after implantation of a permanent transvenous pacemaker

It has been suggested that the incidence of thromboembolic events always increases in patients after insertion of a transvenous pacemaker. Blood samples from twenty consecutive patients (fifteen males and five females) before and after pacemaker implantation was retained for platelet aggregability studies which were analyzed separately with ADP, collagen, epinephrine and arachidonic acid. The maximal amplitude of platelet aggregatory curve was detected by an aggregometer. The samples collected the day before pacemaker implantation (day 0) were used as self-control. Day 1 and day 3 after pacemaker implantation were defined as the acute phase, while day 30 was defined as the chronic phase. The maximal amplitude of platelet aggregatory curve was observed to be lowest on day 1 and then return to normal on day 3 and day 30. The results of platelet aggregability, however, showed no significant difference (P>0.05) between self-control and post-implantation samples. In conclusion, there was no significant change in platelet aggregability for either acute or chronic phases after pacemaker implantation. Antiplatelet medications may not be necessary for the prevention of thromboembolic events after the implantation of a pacemaker.

Predominant tricuspid stenosis secondary to bacterial endocarditis in a patient with permanent pacemaker and balloon dilatation of the stenosis

In a 49-year-old woman with sick sinus syndrome and a permanent VVI pacemaker, severe tricuspid stenosis and its clinical consequences developed 4 years after the attack of endocarditis. Besides the quite unusual occurrence of lead related tricuspid stenosis, successful treatment with balloon dilatation is the unique feature of this case.

Diagnosis of Abnormal Subclavian Venous Flow by Radionuclide Venography in Patients with Permanent Pacemaker

In this study, we investigated the role of radionuclide venography in the diagnosis of abnormal subclavian venous flow due to the lead in patients (pts) with permanent pacemakers. The study was conducted with 53 frames in 52 asymptomatic pts (26 females, mean age 64.5 +/- 15; range 25-89 years). The mean time after implant was 67.6 +/- 47.5 months. Technetium 99m pertecnetate (250 MBq) was given to both antecubital veins simultaneously. The images were acquired in 0.25-second frames for 20 seconds. The pts were evaluated visually in terms of the activity flow through the subclavian veins bilaterally. The retrograde flow in the jugular vein, decrease in flow rate, and subtotal and total obstruction of the subclavian veins were accepted as abnormal venous flow patterns. In 17 pts with abnormal findings, 10 (58.8%) had retrograde flow in the jugular vein, 4 had (23.5%) decreased flow rate, 1 (5.8%) had subtotal and 2 (11.7%) total obstruction in the subclavian vein. The mean of the body diameter of the leads was significantly greater and the percentage of the silicone-insulated leads was higher (76% vs 52%) in the group with abnormal flow. No complication due to the procedure was seen. In conclusion, radionuclide venography, a noninvasive method, may be used easily and safely to show the venous flow abnormalities due to the lead in pts with permanent pacemakers. The abnormal subclavian venous flow was especially seen in pts who had larger leads.

Arm edema, subclavian thrombosis, and pacemakers--a case report

This reports an arm edema that was initially treated as cellulitis and later diagnosed to be subclavian thrombosis due to pacemaker wire irritation. We present an 87-year-old Caucasian man with 5 weeks duration of left arm swelling and pain that was treated with two courses of antibiotics. An axillary venous Doppler study was interpreted as normal with no evidence of venous thrombosis. However, a venogram showed evidence of thrombosis involving the left innominate, subclavian, and axillary veins with multiple collateral veins diverting the blood to the contralateral side and into the superior vena cava. Intravenous anticoagulation was initiated and subsequently the patient was maintained on warfarin (Coumadin). The thrombosis subsequently improved and the original pacemaker was maintained. Arm edema are commonly mistaken for cellulitis, causing a delay in a more definite diagnosis of subclavian thrombosis. In a setting of a patient with pacemaker, subclavian thrombosis should be considered even with a normal screening venous ultrasound test. The incidence, manifestation, venous Doppler, and venogram findings are reviewed and discussed. Upper arm edema and superior vena cava syndrome are the most common presentation of this subclavian thrombosis associated with pacemakers. Venous ultrasound tests may be normal and a venogram is usually required to establish a diagnosis.

Superior vena cava occlusion and/or syndrome related to pacemaker leads

Four cases of pacemaker-related SVC obstruction or syndrome are reported. While two of them lacked any symptom suggestive of SVC obstruction, the other two presented with mild symptoms. None of them received any treatment. One died from a cause unrelated to SVC obstruction, while the others presented no change in their clinical status. A review of the literature suggests that neither thrombotic nor fibrotic obstruction in patients with pacemaker leads is strictly related to the number of abandoned leads, the presence of severed leads, or the time elapsing from pacemaker implant. The diagnosis is clinically made and is confirmed by venography. Only one of the reported deaths is attributable to SVC obstruction. The remaining cases from the literature responded to treatment with heparin, thrombolytic agents, angioplasty, or surgery.

Venous complications after insertion of a transvenous pacemaker

We reviewed the incidence, clinical features, current diagnostic evaluations, and treatments of venous complications that can occur after implantation of a transvenous pacemaker. Of the approximately 80 published articles on the potential venous complications after implantation of a permanent transvenous pacemaker, we selected 63 that addressed the clinical features, diagnosis, and treatment of pacemaker lead-induced venous thrombosis, which occurs in approximately 30 to 45% of patients early or late after implantation of a transvenous pacemaker. Most patients with chronic deep venous thrombosis remain asymptomatic because of the development of an adequate venous collateral circulation. Clinical features of pacemaker lead-induced deep venous thrombosis, although rare, are easily recognized. They should be sought routinely during follow-up of all patients with transvenous pacemaker leads because venous obstruction can interfere with intravenously administered therapy, monitoring of central venous pressure, and revision of a pacemaker lead. Acute deep venous thrombosis is likely to be symptomatic. Early recognition and treatment of acute deep venous thrombosis may help to decrease the potential morbidity and mortality. The definitive diagnosis of pacemaker lead-induced venous thrombosis necessitates contrast-enhanced or digital subtraction venography. Management includes anticoagulation, thrombolytic therapy, surgical intervention, and, recently, percutaneous transluminal balloon venoplasty and depends on the duration, extent, and site of venous occlusion as well as the accompanying symptoms.

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.

Intermittent superior caval venous syndrome due to permanent transvenous electrode

A 75-year-old man began suffering from intermittent episodes of superior caval venous syndrome, seven years after implantation of an endocardial pacemaker via the right cephalic vein. The obstruction of the superior caval vein was confirmed by venography and computed tomography of the chest. Changes of the intrathoracic pressure were considered to be the mechanism responsible for the intermittence of the syndrome.

Limb loss due to transvenous endocardial pacemaker therapy

Although intravenous thrombosis frequently complicates placement of transvenous endocardial leads in patients with permanent pacemakers, clinical manifestations of upper extremity thrombosis are uncommon. Most, including upper extremity edema, cervical venous engorgement, and even superior vena cava syndrome, can be successfully managed with conservative therapy. In the patient described in the present report, clinical manifestations of pacemaker-electrode thrombosis were neither mild nor responsive to conservative therapies: in this patient, pacemaker-electrode thrombosis ultimately required amputation of the right upper extremity. Complications of the magnitude described in this patient emphasize the need for continual review of the indications for pacemaker therapy as understanding of the risk-benefit ratio of this procedure broadens.

Difficulty of extraction of chronically implanted tined ventricular endocardial leads

The dislodgment rate of permanent pacing ventricular and atrial endocardial leads has significantly decreased with the incorporation of tines as a fixation device. In contrast, transvenous manual extraction of chronically implanted endocardial leads is, at times, clinically indicated, particularly when pacemaker system infection is present. The success rate of such extraction attempts for ventricular endocardial leads over the past 5 years was reviewed. Extraction was usually successful (six of seven attempts) in patients with silicone rubber nontined (or short-tined) older ventricular endocardial leads (Group A). However, in patients with newer urethane long-tined ventricular endocardial leads (Group B), extraction was unsuccessful in three of four attempts. Because of entrapment of the distal electrode tip in the right ventricular apex, manual traction of these leads resulted in permanent conductor material stretching with resultant urethane insulator material breakage in the region of the joints with proximal and distal electrodes. The one successful extraction in Group B was technically difficult and appeared to create a significant risk of intracardiac lead separation. This experience indicates that with improved pacemaker lead design decreased lead dislodgment has been obtained at the cost of increased difficulty of ventricular endocardial lead extraction. Such difficulty should be anticipated when a clinical decision is made to attempt to extract the new urethane long-tined ventricular leads.

Total venous obstruction following atrioventricular sequential pacemaker implantation

We describe a case of a 79-year-old woman who developed pain and pitting edema of the upper right extremity due to total venous obstruction following the implantation of an atrioventricular sequential pacemaker. She was treated by arm elevation and anticoagulation after which the pain and edema subsided. To our knowledge, this is the first reported case of this complication occurring following implantation of a dual-chamber pacing system. We recommend that venographic studies be done after implantation if apparent arm swelling occurs, and that anticoagulant therapy be instituted if thrombosis is present.

Special considerations in ventricular pacing in patients with tricuspid valve disease

In patients who have undergone prosthetic tricuspid valve replacement or tricuspid annuloplasty and in whom the pericardial space is obliterated by adhesions from previous operations, the need for ventricular pacing may be met by lead placement in the venous tributaries of the coronary veins. This approach avoids compromise of prosthetic tricuspid valve function and injury to bioprosthetic valves and natural valves repaired by annuloplasty. Although acute stimulation thresholds are slightly higher than those for short-term endocardial implants, stable long-term ventricular pacing has been observed in patients reported in the literature in whom such lead placement was inadvertent and in the 2 patients in the present paper in whom such replacement was deliberate. This method appears to be a safe alternative to standard ventricular pacing techniques under the special circumstances reported here.

Symptomatic upper extremity venous thrombosis associated with permanent transvenous pacemaker electrodes

Symptomatic arm vein thrombosis secondary to permanent transvenous cardiac pacing electrodes is an uncommon occurrence with an incidence of 1 to 3 percent. Two patients with this problem are presented who were treated with streptokinase followed by conventional anticoagulation therapy with heparin and warfarin. Near total resolution of the thromboses was accomplished in both patients. In follow-up periods of nine and 20 months, the patients have remained asymptomatic. An aggressive approach to this problem may decrease the current high morbidity.