The management of cardiac implantable electronic device lead perforations: a multicentre study

Right ventricular lead perforation with iatrogenic injury to an intercostal artery causing haemothorax after pacemaker implant

A woman in her 80s experienced a life-threatening complication of pacemaker implant consisting of subacute right ventricular lead perforation causing iatrogenic injury to an intercostal artery, resulting in a large haemothorax. A CT scan confirmed active bleeding from the fourth intercostal artery. The patient underwent cardiothoracic surgery via a median sternotomy approach, during which the source of the bleeding was sealed, a new epicardial lead was positioned, and the original lead was extracted. This case emphasises the potentially severe consequences of pacemaker lead perforation and secondary injury to adjacent structures. It underscores the importance of early recognition and timely intervention, preferably in a tertiary specialist unit equipped for cardiothoracic surgery and confirms the value of pacemaker interrogation and CT scans for diagnosis.

Cardiac pacing and lead devices management: 25 years of research at EP Europace journal

AIMS

Cardiac pacing represents a key element in the field of electrophysiology and the treatment of conduction diseases. Since the first issue published in 1999, EP Europace has significantly contributed to the development and dissemination of the research in this area.

METHODS

In the last 25 years, there has been a continuous improvement of technologies and a great expansion of clinical indications making the field of cardiac pacing a fertile ground for research still today. Pacemaker technology has rapidly evolved, from the first external devices with limited longevity, passing through conventional transvenous pacemakers to leadless devices. Constant innovations in pacemaker size, longevity, pacing mode, algorithms, and remote monitoring highlight that the fascinating and exciting journey of cardiac pacing is not over yet.

CONCLUSION

The aim of the present review is to provide the current 'state of the art' on cardiac pacing highlighting the most important contributions from the Journal in the field.

Complications in Device Therapy: Spectrum, Prevalence, and Management

PURPOSE OF REVIEW

Cardiac implantable electronic device implant numbers are continually increasing due to the expanding indications and ageing population. This review explores the complications associated with device therapy and discusses ways to minimise and manage such complications.

RECENT FINDINGS

Complications related to device therapy contribute to mortality and morbidity. Recent publications have detailed clear guidelines for appropriate cardiac device selection, as well as consensus documents discussing care quality and optimal implantation techniques. There have also been advances in device technologies that may offer alternative options to patients at high risk of/or already having encountered a complication. Adherence to guidelines, appropriate training, and selection of device, in addition to good surgical technique are key in reducing the burden of complications and improving acceptability of device therapy.

Iatrogenic cardiac perforation due to pacemaker and defibrillator leads: a contemporary multicentre experience

AIMS

To determine the incidence, clinical features, management, and outcomes of pacemaker (PM) and implantable cardioverter-defibrillator (ICD) lead cardiac perforation. Cardiac perforations due to PM and ICD leads are rare but serious complications. Clinical features vary widely and may cause diagnostic delay. Management strategies are non-guideline based due to paucity of data.

METHODS AND RESULTS

A multicentre retrospective series including 3 UK cardiac tertiary centres from 2016 to 2020. Patient, device, and lead characteristics were obtained including 6-month outcomes. Seventy cases of perforation were identified from 10 631 procedures; perforation rate was 0.50% for local implants. Thirty-nine (56%) patients were female, mean ( ± standard deviation) age 74 ( ± 13.8) years. Left ventricular ejection fraction 51 ( ± 13.2) %. Median time to diagnosis was 9 (range: 0-989) days. Computed tomography (CT) diagnosed perforation with 97% sensitivity. Lead parameter abnormalities were present in 86% (whole cohort) and 98.6% for perforations diagnosed >24 h. Chest pain was the commonest symptom, present in 46%. The management strategy was percutaneous in 98.6% with complete procedural success in 98.6%. Pericardial effusion with tamponade was present in 17% and was associated with significantly increased mortality and major complications. Anticoagulation status was associated with tamponade by multivariate analysis (odds ratio 21.7, 95% confidence interval: 1.7-275.5, P = 0.018).

CONCLUSIONS

Perforation was rare (0.50%) and managed successfully by a percutaneous strategy with good outcomes. Tamponade was associated with increased mortality and major complications. Anticoagulation status was an independent predictor of tamponade. Case complexity is highly variable and requires skilled operators with a multi-disciplinary approach to achieve good outcomes.

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.

We should recognize the possibility that a cardiac perforation and tamponade caused by the lead of cardiac implantable electronic devices can occur even years after implantation, despite it being known to occur within 24 h of implantation.

Lead fixation mechanism impacts outcome of transvenous lead extraction: Data from the European Lead Extraction ConTRolled Registry

AIMS

The aims of this study is to characterize the transvenous lead extraction (TLE) population with active (A) compared with passive fixation (PFix) leads and to compare the safety, efficacy, and ease of extracting active fixation (AFix) compared with PFix right atrial (RA) and right ventricular (RV) leads.

METHODS AND RESULTS

The European Lead Extraction ConTRolled Registry (ELECTRa) was analysed. Patients were divided into three groups; those with only AFix, only PFix, and combined Fix leads. Three outcomes were defined. Difficult extraction, complete radiological, and clinical success. Multivariate model was used to analyse the independent effect of Fix mechanism on these outcomes. The study included 2815 patients, 1456 (51.7%) with only AFix leads, 982 (34.9%) with only PFix leads, and 377 (13.4%) with combined Fix leads. Patients with AFix leads were younger with shorter lead dwelling time. Infection was the leading cause for TLE among the combined Fix group with lowest rates among AFix group. No difference in complications rates was noted between patients with only AFix vs. PFix leads. Overall, there were 1689 RA (1046 AFix and 643 PFix) and 2617 RV leads (1441 AFix and 1176 PFix). Multivariate model demonstrated that PFix is independently associated with more difficult extraction for both RA and RV leads, lower radiological success in the RA but has no effect on clinical success.

CONCLUSION

Mechanism of Fix impact the ease of TLE of RA and RV leads and rates of complete radiological success in the RA but not clinical success. These findings should be considered during implantation and TLE procedures.

EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter-defibrillators: endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS)

With the global increase in device implantations, there is a growing need to train physicians to implant pacemakers and implantable cardioverter-defibrillators. Although there are international recommendations for device indications and programming, there is no consensus to date regarding implantation technique. This document is founded on a systematic literature search and review, and on consensus from an international task force. It aims to fill the gap by setting standards for device implantation.

Clinical significance of incidentally detected lead perforations by computed tomography

BACKGROUND

Computed tomography (CT) has an established role in detecting perforation of implanted pacemaker and defibrillator leads. The clinical significance of incidental finding of delayed lead perforation remains unclear. The aim of this study was to assess the prevalence of lead perforation as detected by CT in a cohort of patients undergoing transvenous laser lead extraction and characterize the association between finding of incidental lead perforation with periprocedural outcomes.

METHODS

Consecutive patients that underwent chest CT and lead extraction were retrospectively assessed for presence of lead perforation. A total of 143 patients and 348 leads were assessed. The finding of lead perforation was correlated with findings from peri-procedural transesophageal echocardiography (TEE) and outcomes of the lead extraction procedure.

RESULTS

Lead perforations (including perforations <5 mm and ≥5 mm) were detected in 66 (46%) patients and 73 (21%) leads. Lead perforation ≥5 mm were less common and detected in 13 (9%) of patients and 14 (4%) of leads. There was no significant difference in the rates of peri-procedural death, cardiac avulsion, cardiac tamponade or post-extraction pericardial effusion in patients with and without lead perforation.

CONCLUSIONS

Incidental delayed lead perforations detected by CT are common and do not correlate with significant TEE findings or adverse peri-procedural outcomes in patients undergoing lead extraction. Larger studies are needed to further characterize the frequency and safety of these findings.

An Interesting Case of Acute Asymptomatic Lead Perforation of a Permanent Cardiac Pacemaker

Acute complications of pacemaker implantation such as lead dislodgement, pneumothorax, and myocardial perforation are not uncommon. Management of these usually requires reintervention. We herein describe lead perforation after a single chamber pacemaker implantation, which was successfully managed conservatively. This case underscores that vigilant monitoring post lead perforation can avoid a redo procedure.

Feasibility and Safety of Percutaneous Lead Revision for Subacute and Delayed Cardiac Device Lead Perforation

OBJECTIVES

This study assessed the management approach and outcome of subacute (1 to 30 days post-implantation) and delayed (>30 days) cardiac perforation by pacemaker or implantable cardioverter-defibrillator (ICD) leads.

BACKGROUND

Implantation of pacemaker and ICD leads is associated with a small but serious risk of cardiac perforation. Appropriate management remains uncertain.

METHODS

The study population included all patients referred to a single institution for subacute or delayed lead perforation after pacemaker or ICD implantation (identified after hospital discharge) during the period from 2007 to 2020. The approach and outcome of lead management were retrospectively assessed.

RESULTS

Fifty-four cases of cardiac perforation were identified (35 females; mean age: 75.5 ± 9.7 years). Cardiac perforation was related to a pacemaker lead in 36 patients, and the perforating leads were originally placed in the right ventricular apex in 41 patients. The average time from lead implantation to first presentation of symptoms of perforation was 60.8 ± 89.1 days (range 2 to 412 days). Symptoms suggestive of cardiac perforation were reported by 31 patients (57.4%). Twenty three patients were asymptomatic, in whom lead perforation was discovered incidentally on radiographic imaging, suggesting lead migration or anomalous electrical data on device interrogation. In all patients, the leads were removed or repositioned by the percutaneous approach, with no major periprocedural complications and without surgical intervention.

CONCLUSIONS

In this largest series to date of subacute or delayed cardiac device lead perforation, percutaneous repositioning or replacement of the perforating lead was found to be a safe and effective management approach.

Cardiac Implantable Electronic Miniaturized and Micro Devices

Advancement in the miniaturization of high-density power sources, electronic circuits, and communication technologies enabled the construction of miniaturized electronic devices, implanted directly in the heart. These include pacing devices to prevent low heart rates or terminate heart rhythm abnormalities ('arrhythmias'), long-term rhythm monitoring devices for arrhythmia detection in unexplained syncope cases, and heart failure (HF) hemodynamic monitoring devices, enabling the real-time monitoring of cardiac pressures to detect and alert for early fluid overload. These devices were shown to prevent HF hospitalizations and improve HF patients' life quality. Pacing devices include permanent pacemakers (PPM) that maintain normal heart rates, defibrillators that are capable of fast detection and the termination of life-threatening arrhythmias, and cardiac re-synchronization devices that improve cardiac function and the survival of HF patients. Traditionally, these devices are implanted via the venous system ('endovascular') using conductors ('endovascular leads/electrodes') that connect the subcutaneous device battery to the appropriate cardiac chamber. These leads are a potential source of multiple problems, including lead-failure and systemic infection resulting from the lifelong exposure of these leads to bacteria within the venous system. One of the important cardiac innovations in the last decade was the development of a leadless PPM functioning without venous leads, thus circumventing most endovascular PPM-related problems. Leadless PPM's consist of a single device, including a miniaturized power source, electronic chips, and fixating mechanism, directly implanted into the cardiac muscle. Only rare device-related problems and almost no systemic infections occur with these devices. Current leadless PPM's sense and pace only the ventricle. However, a novel leadless device that is capable of sensing both atrium and ventricle was recently FDA approved and miniaturized devices that are designed to synchronize right and left ventricles, using novel intra-body inner-device communication technologies, are under final experiments. This review will cover these novel implantable miniaturized cardiac devices and the basic algorithms and technologies that underlie their development. Advancement in the miniaturization of high-density power sources, electronic circuits, and communication technologies enabled the construction of miniaturized electronic devices, implanted directly in the heart. These include pacing devices to prevent low heart rates or terminate heart rhythm abnormalities ('arrhythmias'), long-term rhythm monitoring devices for arrhythmia detection in unexplained syncope cases, and heart failure (HF) hemodynamic monitoring devices, enabling the real-time monitoring of cardiac pressures to detect and alert early fluid overload. These devices were shown to prevent HF hospitalizations and improve HF patients' life quality. Pacing devices include permanent pacemakers (PPM) that maintain normal heart rates, defibrillators that are capable of fast detection and termination of life-threatening arrhythmias, and cardiac re-synchronization devices that improve cardiac function and survival of HF patients. Traditionally, these devices are implanted via the venous system ('endovascular') using conductors ('endovascular leads/electrodes') that connect the subcutaneous device battery to the appropriate cardiac chamber. These leads are a potential source of multiple problems, including lead-failure and systemic infection that result from the lifelong exposure of these leads to bacteria within the venous system. The development of a leadless PPM functioning without venous leads was one of the important cardiac innovations in the last decade, thus circumventing most endovascular PPM-related problems. Leadless PPM's consist of a single device, including a miniaturized power source, electronic chips, and fixating mechanism, implanted directly into the cardiac muscle. Only rare device-related problems and almost no systemic infections occur with these devices. Current leadless PPM's sense and pace only the ventricle. However, a novel leadless device that is capable of sensing both atrium and ventricle was recently FDA approved and miniaturized devices designed to synchronize right and left ventricles, using novel intra-body inner-device communication technologies, are under final experiments. This review will cover these novel implantable miniaturized cardiac devices and the basic algorithms and technologies that underlie their development.

Transvenous revision of leads with cardiac perforation following device implantation-Safety, outcome, and complications

INTRODUCTION

Cardiac perforation is a rare complication of cardiac implantable electronic device (CIED) implantation. Transvenous revision of perforated leads is associated with the risk of cardiac tamponade and death. Little is known about periprocedural complications and outcome of these patients.

METHODS AND RESULTS

All patients referred to our department with evidence or suspicion of cardiac perforation following CIED implantation underwent chest X-ray, transthoracic echocardiography, device interrogation, and, if necessary, a cardiac computed tomography (CT)-scan to diagnose lead perforation and associated complications. Transvenous lead revision (TLR) was performed in all patients with evidence of lead perforation. Patient characteristics, procedural complications, and outcome were recorded and analyzed. Fifty-six patients (75 ± 10 years, 43% male) were diagnosed with cardiac perforation, 34 patients (61%) early within 30 days post-implantation, and 22 patients (39%) thereafter. The most frequent perforation site was the right ventricular (RV) apex (75%), followed by the RV free wall (16%) and the right atrial appendage (9%). A total of 16 patients (29%) presented with severe complications; 12 patients (21%) with pericardial effusion treated by pericardiocentesis before lead revision and four patients (7%) with hematothorax requiring drainage. Late perforations showed significantly more frequent cardiac tamponades (P = .041). TLR was performed without further complications in 54 patients (96%). None of the patients required surgical treatment or experienced in-hospital death.

CONCLUSIONS

Cardiac perforation following CIED implantation is associated with severe complications in nearly one-third of the cases. Transvenous revision of the perforated lead can safely be performed with a very low complication rate.

Percutaneous management of atrium and lung perforation: A case report

BACKGROUND

Cardiac perforation by a transvenous lead is an uncommon but serious complication. Delayed perforation, defined as migration and perforation of an implanted lead at least 1 mo after implantation, is exceedingly rare and prone to underdiagnosis, and its optimal management is currently unclear. We report an uneventful transvenous extraction of an active fixation lead that led to delayed perforation of the right atrium, pericardium, and lung, disclosed 2 mo after implantation.

CASE SUMMARY

A 61-year-old woman with atrial lead perforation was transferred to our center. She had a dual-chamber pacemaker with active fixation leads implanted 8 mo previously. At 2 mo after implantation, she complained of chest pain and hemoptysis. Chest computed tomography revealed atrial lead migration into the lung. No pericardial or pleural effusion was detected. She underwent transvenous lead extraction in the electrophysiology room with surgical backup. The percutaneous subxiphoid pericardial puncture was performed first, and a pigtail catheter was left in the pericardial sac throughout the procedure. Then, a new active fixation lead was implanted at a different site with less tension. After the active screw was retracted, the culprit atrial lead was explanted successfully with simple traction. There were no complications during or after the procedure. The patient recovered well and follow-up was uneventful.

CONCLUSION

Percutaneous management of perforated active fixation lead outside the pericardial sac under surgical backup is safe and effective.