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Khan IA, Mazhar S. Unintentional Implantation of a Permanent Pacemaker Lead Across a Patent Foramen Ovale Leading to Left Ventricular Pacing. Cureus 2023; 15:e49277. [PMID: 38143598 PMCID: PMC10746920 DOI: 10.7759/cureus.49277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/26/2023] Open
Abstract
Unintentional placement of a left ventricular lead through a patent foramen ovale (PFO) is an uncommon and underdiagnosed complication. Normal single- or dual-chamber permanent pacemaker implantation involves placing a lead across the tricuspid valve into the right ventricle. In a very rare case instead of the lead going into the right ventricle, it goes through the PFO and across the mitral valve into the left ventricle (LV) resulting in LV pacing. We describe a case of one of our patients who presented with syncope due to bifascicular block and underwent a dual-chamber pacemaker implantation at a local hospital. He had a background of paroxysmal atrial fibrillation and sarcoidosis. Post-procedure, he was discharged with an inadvertent lead in the LV that was not identified. Abnormal placement of LV leads can result in serious complications including thromboembolism, mitral regurgitation, and left-sided endocarditis. Treatment options include extraction of the lead or anticoagulation.
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Affiliation(s)
- Ibrar A Khan
- Department of Cardiology, Southend University Hospital, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
| | - Sajjad Mazhar
- Department of Cardiology, Southend University Hospital, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
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2
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Pollock J, Pollema T, Pretorius V, Birgersdotter-Green U, Cronin B. Percutaneous Laser Lead Extraction of an Inadvertently Placed Left-Sided Pacemaker Lead. J Cardiothorac Vasc Anesth 2017; 31:663-668. [DOI: 10.1053/j.jvca.2016.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Indexed: 11/11/2022]
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Almomani A, Abualsuod A, Paydak H, Peer W, Maskoun W. Chronic lead malposition diagnosis and management: discussion of two cases and literature review. Clin Case Rep 2017; 5:270-276. [PMID: 28265389 PMCID: PMC5331254 DOI: 10.1002/ccr3.819] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 10/31/2016] [Accepted: 12/19/2016] [Indexed: 11/08/2022] Open
Abstract
Management of lead malposition is crucial to avoid complications and is carried out on case-by-case bases. The 12-lead ECG during pacing and chest X-ray are essential during initial workup and recommended for new patients to the device clinic. Echocardiography and CT scan are important to confirm the location and plan appropriate therapy.
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Affiliation(s)
- Ahmed Almomani
- Division of Cardiology University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Amjad Abualsuod
- Department of Internal Medicine University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Hakan Paydak
- Division of Cardiology University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Wilburt Peer
- Department of Internal Medicine University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Waddah Maskoun
- Division of Cardiology University of Arkansas for Medical Sciences Little Rock Arkansas USA; Division of Cardiology Central Arkansas Veterans Healthcare System Little Rock Arkansas USA
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Ohlow MA, Roos M, Lauer B, Von Korn H, Geller JC. Incidence, predictors, and outcome of inadvertent malposition of transvenous pacing or defibrillation lead in the left heart. Europace 2015; 18:1049-54. [PMID: 26462705 DOI: 10.1093/europace/euv270] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 07/16/2015] [Indexed: 12/19/2022] Open
Abstract
AIMS Inadvertent lead malposition (ILM) in the left heart is a potential cause of thromboembolism and, therefore, a complication of heart rhythm device implantation [HRDI: pacemaker, implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy (CRT)]. The aim of the study was to report the incidence and clinical outcome of ILM. METHODS AND RESULTS Postoperative lateral and posterior-anterior chest X-rays of all consecutive patients undergoing HRDI from 2007 through 2012 were retrospectively analysed. During the study period, 2579 patients underwent HRDI at our institution. ILM was present in six patients (0.34%, 50% male, mean age 71.5 ± 9.4 years). In one and four patients, malposition was in the left atrium and ventricle, respectively. In one case, the RV-lead was placed in a coronary sinus branch. In four patients, ILM was detected intra-operatively or in the early postoperative period. In the remaining two patients, malposition was not recognized and they suffered cerebral embolism 4 months and 1 year after implantation. ILM was corrected during the same hospital stay (four cases), or during follow-up by percutaneous extraction (two cases). Patients with ILM had significantly more scoliosis (16.7 vs. 0.17%; P = 0.01), congenital heart disease (CHD: 33.3 vs. 0.4%; P = 0.003), or prior surgery for CHD (16.7 vs. 0.5%; P = 0.03). The likelihood of ILM was also increased when HRDI was performed by an inexperienced operator (<100 HRDI; P < 0.01). CONCLUSION The incidence of ILM was 0.34% in our series. Scoliosis, CHD, prior correction of CHD, and limited operator experience were identified as risk factors.
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Affiliation(s)
- Marc-Alexander Ohlow
- Department of Cardiology, Zentralklinik, Robert-Koch-Allee 9, Bad Berka 99437, Germany
| | - Marcus Roos
- Clinic for Electrophysiology, Heart Center, Salzburger Leite 1, Bad Neustadt 67616, Germany
| | - Bernward Lauer
- Department of Cardiology, Zentralklinik, Robert-Koch-Allee 9, Bad Berka 99437, Germany
| | - Hubertus Von Korn
- Medizinische Klinik I, Krankenhaus Hetzelstift, Neustadt/Weinstrasse, Germany
| | - Johann Christoph Geller
- Department of Invasive Electrophysiology, Zentralklinik, Robert-Koch-Allee 9, Bad Berka 99437, Germany
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Bahadorani JN, Schricker AA, Pretorius VG, Birgersdotter-Green U, Dominguez A, Mahmud E. Percutaneous extraction of inadvertently placed left-sided pacemaker leads with complete cerebral embolic protection. Catheter Cardiovasc Interv 2015; 86:777-85. [PMID: 25581608 DOI: 10.1002/ccd.25826] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 12/01/2014] [Accepted: 01/03/2015] [Indexed: 11/06/2022]
Abstract
Lead wire malposition is a known, but rare complication of permanent pacemaker or defibrillator implantation. The actual incidence and prevalence is unknown and management options for inadvertent left ventricular lead malposition have not been uniform. Current recommendations include systemic anticoagulation with warfarin or surgical lead removal with circulatory arrest for compelling clinical scenarios. Percutaneous left-sided lead extraction is contraindicated due to the potentially increased risk of thromboembolic complications associated with this procedure. To our knowledge, this is the first report of percutaneous extraction of inadvertently placed left ventricular and left atrial endocardial pacemaker leads with flow-preserving complete cerebral embolic protection. We also review the current literature regarding the incidence, management, and percutaneous extraction of left-sided cardiac leads.
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Affiliation(s)
- John N Bahadorani
- Division of Cardiovascular Medicine and Sulpizio Cardiovascular Center, University of California, San Diego, California
| | - Amir A Schricker
- Division of Cardiovascular Medicine and Sulpizio Cardiovascular Center, University of California, San Diego, California
| | - Victor G Pretorius
- Division of Cardiovascular Medicine and Sulpizio Cardiovascular Center, University of California, San Diego, California
| | - Ulrika Birgersdotter-Green
- Division of Cardiovascular Medicine and Sulpizio Cardiovascular Center, University of California, San Diego, California
| | - Arturo Dominguez
- Division of Cardiovascular Medicine and Sulpizio Cardiovascular Center, University of California, San Diego, California
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine and Sulpizio Cardiovascular Center, University of California, San Diego, California
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Trohman RG. To the editor-comment on six uneventful years with a pacing lead in the left ventricle. Heart Rhythm 2013; 10:e81. [PMID: 23994076 DOI: 10.1016/j.hrthm.2013.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Indexed: 11/18/2022]
Affiliation(s)
- Richard G Trohman
- Division of Cardiology, Clinical Cardiac Electrophysiology Service, Department of Medicine, Rush University Medical Center, Chicago, Illinois.
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Bodian M, Aw F, Bamba MN, Kane A, Jobe M, Tabane A, Mbaye A, Sarr SA, Diao M, Sarr M, Bâ SA. Sinus venosus atrial septal defect: a rare cause of misplacement of pacemaker leads. Int Med Case Rep J 2013; 6:29-32. [PMID: 23847433 PMCID: PMC3707482 DOI: 10.2147/imcrj.s45784] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Routine implantation of pacemakers and implantable cardioverter defibrillators is not commonly associated with complications. However, in some cases we see misplacement of pacemaker leads which is most often related to the presence of underlying cardiac anomalies. We report the case of misplacement of a pacemaker lead into the left ventricle of a 56-year-old patient paced in VVI/R mode and with a tined type pacemaker lead because of a symptomatic complete atrioventricular block. Electrocardiogram showed a pacemaker-generated rhythm with a right bundle branch block pattern. Chest X-ray showed the pacemaker lead located relatively high in relation to the diaphragm. Echocardiography visualized the pacemaker lead in the left heart chambers (atrium and ventricle), hence confirming its aberrant course. Further, the defect causing its passage to the left heart chambers was a sinus venosus atrial septal defect. The patient reported no complication related to the misplacement of the lead. After a brief period of oral anticoagulation, the lead was inserted into the right ventricle by percutaneous technique.
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Affiliation(s)
- Malick Bodian
- Department of Cardiology, Aristide Le Dantec Teaching Hospital
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Wynn GJ, Weston C, Cooper RJ, Somauroo JD. Inadvertent left ventricular pacing through a patent foramen ovale: identification, management and implications for postpacemaker implantation checks. BMJ Case Rep 2013; 2013:bcr-2012-008312. [PMID: 23814191 DOI: 10.1136/bcr-2012-008312] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A dual chamber permanent pacemaker was implanted into an asymptomatic man with complete (third degree) heart block because of the risk of asystole. The ventricular lead was thought to have been attached to the right ventricular septum; however, it inadvertently passed through a patent foramen ovale into the left ventricle. Although the postprocedure ECG showed right bundle branch block this was thought to be due to the presumed septal positioning of the pacing lead. Lead misplacement was not detected on posterioanterior chest X-ray but was clearly demonstrated by transthoracic echocardiography, and subsequently on lateral chest X-ray. The lead was successfully removed and repositioned correctly at the next available opportunity without complication or sequelae.
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Affiliation(s)
- Gareth J Wynn
- Institute of Cardiovascular Medicine and Science, Liverpool, UK
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Abstract
PURPOSE OF REVIEW Transseptal endocardial left-ventricular pacing has a number of potential advantages over left-ventricular epicardial pacing from the coronary sinus, for implantation of cardiac resynchronization therapy (CRT) devices. In this study we review the risks and potential benefits. RECENT FINDINGS Permanent transseptal endocardial pacing has been shown to be clinically feasible. Different methods have been described, including a superior, inferior or mixed approach. Endocardial pacing has a number of potential advantages over conventional left-ventricular pacing from the coronary sinus. It may be possible to achieve more effective CRT through optimizing the left-ventricular lead position, which is possible because of the greater choice of stimulation site. Endocardial rather than epicardial stimulation may result in more rapid ventricular activation and may be less arrhythmogenic. Disadvantages of this approach include the risk of thromboembolism and the potential for interaction with the mitral valve. SUMMARY Transseptal endocardial left-ventricular pacing shows promise for use in cardiac resynchronization therapy. The safety and effectiveness of this technique should now be tested in larger clinical trials.
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Rodriguez Y, Baltodano P, Tower A, Martinez C, Carrillo R. Management of symptomatic inadvertently placed endocardial leads in the left ventricle. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:1192-200. [PMID: 21671951 DOI: 10.1111/j.1540-8159.2011.03146.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are limited data regarding the clinical care of inadvertently placed endocardial leads in the left ventricle (LV). We clarified the appropriate management within the context of our experience and published literature. METHODS Hospital charts dating from October 2008 to December 2010 were reviewed at a high-volume cardiovascular tertiary referral center. Six patients were identified with inadvertently placed leads in the LV through an atrial septal defect. RESULTS Six patients (four males, two females) underwent LV lead removal, four through open surgical intervention and two percutaneously. Three (50%) patients presented with severe mitral regurgitation; one (16%) with a thromboembolic transient ischemic attack and two (33%) were asymptomatic. The mean age was 68.5 ± 8.48 years (55-78). Mean ejection fraction was 38.47 ± 11.1% (25%-50%). Four patients (66%) had a pacemaker and two (33%) had implantable cardioverter defibrillators. Comorbidities consisted of diabetes mellitus (50%), chronic renal failure (16%), severe chronic pulmonary hypertension (16%), and congestive heart failure (33%). Hypertension and coronary arterial disease were present in all patients. All patients had complete extraction or repositioning without intraoperative complications or mortality within 30 days. At 6-month follow-up, the patient with severe pulmonary hypertension died of pneumonia and the other five were alive and well. CONCLUSION The avoidance and early recognition of inadvertently placed endocardial leads in the LV is imperative in order to avoid potentially serious sequelae and invasive interventions. Treatment usually consists of surgical extraction, although anticoagulation and percutaneous simple traction techniques are an option in certain scenarios.
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Affiliation(s)
- Yasser Rodriguez
- Division of Cardiology and Thoracic and Cardiovascular Surgery, University of Miami Hospital, Miami, FL 33125, USA
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12
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Left ventricular endocardial stimulation for severe heart failure. J Am Coll Cardiol 2010; 56:747-53. [PMID: 20797486 DOI: 10.1016/j.jacc.2010.04.038] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 02/22/2010] [Accepted: 04/13/2010] [Indexed: 11/23/2022]
Abstract
Biventricular resynchronization, a therapy recommended for patients presenting with left ventricular (LV) dysfunction and ventricular dyssynchrony, requires the implantation of an LV lead, usually placed in a lateral or posterolateral tributary of the coronary sinus. Despite important progress made in the development of dedicated instrumentation, the procedure remains sometimes challenging and unsuccessful in a minority of patients. In the rare instances of unsuccessful transvenous implantations occurring in the presence of major surgical contraindications, a few operators have implanted the LV lead transseptally, an approach limited by technical difficulties and by the thromboembolic risk associated with the presence of a lead inside the LV cavity. The interest in this approach was recently renewed by 2 studies in an animal model and in humans, respectively, which both found a distinctly superior hemodynamic performance associated with endocardial compared with epicardial stimulation. This review discusses the advantages and disadvantages of LV endocardial stimulation, examines the various techniques of LV endocardial stimulation, and projects their future applications in light of these highly promising recent results. The implementation of endocardial stimulation will ultimately depend on: 1) the development of safe, effective, and durable instrumentation, and reliable and reproducible intraprocedural methods to identify the optimal site of stimulation; and 2) the completion of controlled trials confirming the superiority of this technique compared with standard cardiac resynchronization therapy.
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Heck PM, Hoole SP, Cooper JP, Begley DA. Inadvertent placement of left ventricular endocardial pacing lead. J Cardiovasc Med (Hagerstown) 2010; 13:656-9. [PMID: 20686415 DOI: 10.2459/jcm.0b013e32833dae5f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bhave PD, Lee BK. The Path Less Taken. Card Electrophysiol Clin 2010; 2:273-275. [PMID: 28770762 DOI: 10.1016/j.ccep.2010.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This case report illustrates the importance of obtaining and carefully analyzing a paced ECG immediately after pacemaker implantation. Early recognition of a malpositioned lead in the left ventricle would allow correction before the lead becomes difficult to remove. Chest radiography and echocardiography are simple tests that can help confirm appropriate lead placement.
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Affiliation(s)
- Prashant D Bhave
- Department of Cardiology, University of California San Francisco Medical Center, 505 Parnassus Avenue, M1186, San Francisco, CA 94121, USA
| | - Byron K Lee
- Department of Cardiology, University of California San Francisco Medical Center, Electrophysiology Service, 500 Parnassus Avenue, San Francisco, CA 94143-1354, USA
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Stouffer CW, Shillingford MS, Miles WM, Conti JB, Beaver TM. Lead astray: minimally invasive removal of a pacing lead in the left ventricle. Clin Cardiol 2010; 33:E109-10. [PMID: 20552628 PMCID: PMC6653419 DOI: 10.1002/clc.20728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Accepted: 11/25/2009] [Indexed: 11/07/2022] Open
Abstract
Pacemaker and implantable cardioverter defibrillator (ICD) leads are placed routinely with few notable complications. A rarely described complication of transvenous lead placement is malpositioning into the left ventricle. This situation can cause additional complications in the form of thromboembolic events. We present a case of a malpositioned left ventricular lead that was successfully removed with a minimally invasive technique.
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Affiliation(s)
- Chadwick W Stouffer
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, USA.
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LAU ERNESTW. Achieving Permanent Left Ventricular Pacing-Options and Choice. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:1466-77. [DOI: 10.1111/j.1540-8159.2009.02514.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH, Epstein LM, Friedman RA, Kennergren CEH, Mitkowski P, Schaerf RHM, Wazni OM. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009; 6:1085-104. [PMID: 19560098 DOI: 10.1016/j.hrthm.2009.05.020] [Citation(s) in RCA: 768] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Indexed: 12/20/2022]
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Lau EW. A streamlined technique of trans-septal endocardial left ventricular lead placement. J Interv Card Electrophysiol 2009; 26:73-81. [DOI: 10.1007/s10840-009-9395-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 03/02/2009] [Indexed: 10/20/2022]
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Nordbeck P, Langenfeld H, Krein A, Bauer WR, Ritter O. Pacing lead inserted via the subclavian artery caused acute coronary syndrome. Herzschrittmacherther Elektrophysiol 2009; 19:188-92. [PMID: 19214420 DOI: 10.1007/s00399-008-0016-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Accepted: 07/31/2008] [Indexed: 11/24/2022]
Abstract
UNLABELLED Introduction of a cardiac pacing lead via the subclavian artery is a rare complication in the process of pacemaker implantation. Removal of the lead from the arterial system imposes an increased risk of cerebral thrombembolism and, in case of arterial puncture, an increased risk of bleeding. METHODS AND RESULTS Here we describe an acute coronary syndrome caused by a pacing lead inserted via the subclavian artery with the tip implanted close to the ostium of the left coronary artery. We further describe the successful removal of the lead and give a short overview of the literature. CONCLUSION In cases where a pacemaker or ICD lead has already been placed in the left ventricle for an extended period of time and there is no indication for replacement like insufficient threshold levels, infection, or thrombembolic events, the lead can be left in place and the patient be treated with anticoagulants. In asymptomatic patients with additional indications for cardiac surgery simultaneous lead extraction should be considered. In patients with a history of thrombembolic events, or in patients with other indications for lead replacement, lead extraction should preferably be performed by cardiac surgery, rather than by percutaneous extraction.
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Affiliation(s)
- Peter Nordbeck
- Medizinische Klinik und Poliklinik I, Universität Würzburg, Josef-Schneider-Strasse 2, Würzburg, Germany.
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Abstract
Permanent cardiac pacing remains the only effective treatment for chronic, symptomatic bradycardia. In recent years, the role of implantable pacing devices has expanded substantially. At the beginning of the 21st century, exciting developments in technology seem to happen at an exponential rate. Major advances have extended the use of pacing beyond the arrhythmia horizon. Such developments include dual-chamber pacers, rate-response algorithms, improved functionality of implantable cardioverter defibrillators, combinations of sensors for optimum physiological response, and advances in lead placement and extraction. Cardiac pacing is poised to help millions of patients worldwide to live better electrically. We review pacing studies of sick-sinus syndrome, neurocardiogenic syncope, hypertrophic obstructive cardiomyopathy, and cardiac resynchronisation therapy, which are common or controversial indications for cardiac pacing. We also look at the benefits and complications of implantation in specific arrhythmias, suitability of different pacing modes, and the role of permanent pacing in the management of patients with heart failure.
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Affiliation(s)
- Richard G Trohman
- Department of Medicine, Section of Cardiology, Electrophysiology, Arrhythmia, and Pacemaker Service, Rush-Presbyterian-St Luke's Medical Centre and Rush Medical College, Chicago, IL 60612, USA.
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Kassotis J, Mirhoseni N, Makan M, Reddy CV. Asymptomatic left ventricular permanent pacemaker malposition detected on routine follow-up--a case report. Angiology 2001; 52:859-62. [PMID: 11775628 DOI: 10.1177/000331970105201208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The authors present an asymptomatic left ventricular pacemaker lead malposition that was detected upon routine 2-D Echocardiography. Clinical implication diagnosis and therapeutic options on left ventricular pacemaker lead malposition are discussed.
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Affiliation(s)
- J Kassotis
- Department of Electrophysiologic Services, Clinical Affiliate of the New Presbyterian Hospital System, Brooklyn, NY 11215, USA.
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Bracke FA, Meijer A, van Gelder LM. Pacemaker lead complications: when is extraction appropriate and what can we learn from published data? Heart 2001; 85:254-9. [PMID: 11179258 PMCID: PMC1729652 DOI: 10.1136/heart.85.3.254] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- F A Bracke
- Department of Cardiology, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, Netherlands.
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Van Gelder BM, Bracke FA, Oto A, Yildirir A, Haas PC, Seger JJ, Stainback RF, Botman KJ, Meijer A. Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: a multicenter experience and review of the literature. Pacing Clin Electrophysiol 2000; 23:877-83. [PMID: 10833709 DOI: 10.1111/j.1540-8159.2000.tb00858.x] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Three patients from different centers with pacemaker or ICD leads endocardially implanted in the left ventricle are described. All leads, two ventricular pacing leads and one ICD lead, were inserted through a patent foramen ovale or an atrial septum defect. The diagnosis was made 9 months, 14 months, and 16 years, respectively, after implantation. All patients had right bundle branch block configuration during ventricular pacing. Chest X ray was suggestive of a left-sided positioned lead except in the ICD patient. Diagnosis was confirmed with echocardiography in all patients. One patient with a ventricular pacing lead presented with a transient ischemic attack at 1-month postimplantation. During surgical repair of the atrial septum defect 14 months later, the lead was extracted and thrombus was attached to the lead despite therapy with aspirin. The other patients were asymptomatic without anticoagulation (9 months and 16 years after implant). No thrombus was present on the ICD lead at the time of the cardiac transplantation in one patient. We reviewed 27 patients with permanent leads described in the literature. Ten patients experienced thromboembolic complications, including three of ten patients on antiplatelet therapy. The lead was removed in six patients, anticoagulation with warfarin was effective for secondary prevention in the four remaining patients. In the asymptomatic patients, the lead was removed in five patients. In the remaining patients, 1 patient was on warfarin, 2 were on antiplatelet therapy, and in 3 patients the medication was unknown. After malposition was diagnosed, three additional patients were treated with warfarin. In conclusion, if timely removal of a malpositioned lead in the left ventricle is not preformed, lifelong anticoagulation with warfarin can be recommended as the first choice therapy and lead extraction reserved in case of failure or during concomitant surgery.
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Affiliation(s)
- B M Van Gelder
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
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Abstract
The common reasons for removal of pacing and defibrillator leads are infection, malfunction, or design defects such as fracture of J wires in Teletronics Accufix leads (Telectronics Pacing, Englewood, CO), which impose considerable risk for cardiac morbidity and mortality. Chronically implanted leads are fixed to the myocardium by fibrous tissue. Fibrous scar tissue may also encase the lead along its course. Furthermore, fragility of the lead and its tendency to break when extraction force is applied to overcome resistance imparted by the scar tissue add to the challenge of lead extraction. Thus, the extraction of chronically implanted leads is an important issue. Until a few years ago, the only methods available for the removal of chronically implanted leads were traction on the proximal segment of the lead and cardiac surgery. New techniques were developed to extract the leads by a transvenous approach using locking stylets, sheaths, snares, and retrieval baskets. Lead extraction using intravascular countertraction methods has since evolved as a specialty of its own. Progress has also been made in developing other system, such as Excimer laser energy for lead extraction. In this article, we discuss principles, techniques, and experience with these methods of extraction of chronic pacemaker and defibrillator leads.
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Affiliation(s)
- B K Kantharia
- Division of Cardiac Electrophysiology, Hahnemann University Hospital, Philadelphia, PA 19102, USA
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Affiliation(s)
- R K Thakur
- Arrhythmia Service, Thoracic and Cardiovascular Institute, Lansing, MI 48910, USA
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Alt E, Neuzner J, Binner L, Göhl K, Res JC, Knabe UH, Zehender M, Reinhardt J. Three-year experience with a stylet for lead extraction: a multicenter study. Pacing Clin Electrophysiol 1996; 19:18-25. [PMID: 8848372 DOI: 10.1111/j.1540-8159.1996.tb04786.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The extraction of chronically implanted and infected pacemaker and defibrillator leads is an important issue. This article describes the experience gathered between 1990 and 1994 by seven European centers regarding a locking stylet that is uniformly applicable for a wide variety of internal pacing coil diameters. This interventional locking stylet for lead extraction has an outer diameter of 0.4 mm (0.016 inches). The stylet consists of a hollow shaft in which an inner traction wire is embedded. At the tip of the inner traction wire an anchoring mechanism, which can be opened by retraction, is applied. Removal attempts were made for 150 leads, 110 in ventricular and 40 in atrial positions. RESULTS Complete removal was possible in 122 cases (81%). Partial removal was possible in 18 cases (12%). Failure to remove the lead with the extraction stylet was experienced in 10 cases (7%). In seven patients, the leads were removed by cardiothoracic surgery; 3 defective leads were left in place. There were no serious complications associated with the procedure. None of the patients died. CONCLUSION The experience with this extraction stylet for lead removal has shown good results. Despite a low complication rate thus far, each case for lead removal should be judged on the individual basis of benefit-to-risk ratio.
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Affiliation(s)
- E Alt
- Klinikum rechts der Isar, Munich, Germany
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27
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Coman JA, Trohman RG. Incidence and electrocardiographic localization of safe right bundle branch block configurations during permanent ventricular pacing. Am J Cardiol 1995; 76:781-4. [PMID: 7572654 DOI: 10.1016/s0002-9149(99)80226-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The usual morphology for paced events originating from the right ventricle has a left bundle branch block (BBB) pattern. However, in a few patients, right BBB configurations are identified. It is important to differentiate safe right BBB patterns from those caused by septal or free wall perforation. Paced electrocardiograms were examined in 179 consecutive patients who underwent pacemaker placement. Fourteen patients (8%) were identified with right BBB configurations. Posteroanterior and lateral chest radiographs and echocardiograms were evaluated specifically to identify the pacing lead location in this group. In addition, 152 paced episodes from published reports were combined with our population to create an electrocardiographic algorithm differentiating right ventricular septum, right ventricular apex, coronary venous, and left ventricular pacing. Chest radiographs and echocardiographic lead locations correlated perfectly in the 11 patients available for echocardiograms. With use of a left superior axis and precordial transition by lead V3, right ventricular right BBB morphologies were correctly detected in 18 of 21 patients (86% sensitivity, 99% specificity) and appropriately separated from left ventricular pacing in 18 of 19 patients (95% positive predictive value). Therefore, 12-lead electrocardiograms are a rapid, reliable means of separating right and left ventricular right BBB pacing morphologies. Prudent use of these criteria will help eliminate unnecessary echocardiography, anticoagulation, and lead revision.
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Affiliation(s)
- J A Coman
- Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA
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Sharifi M, Sorkin R, Sharifi V, Lakier JB. Inadvertent malposition of a transvenous-inserted pacing lead in the left ventricular chamber. Am J Cardiol 1995; 76:92-5. [PMID: 7793416 DOI: 10.1016/s0002-9149(99)80812-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In conclusion, we propose the following approach to prevent and manage lead malposition in the left ventricle: A 12-lead electrocardiogram in the paced mode and an anterior and lateral chest view should be thoroughly inspected shortly after pacemaker implantation. A definitive diagnosis of malposition can be established with these tests. Development of any neurologic symptoms should be attributed to the malpositioned lead until proved otherwise. In such patients, serious consideration should be given to transcatheter or surgical lead extraction after a period of anticoagulation. If this is not possible, chronic anticoagulation with warfarin must be initiated, achieving an international normalized ratio of > or = 2.5. Antiplatelet therapy alone may not confer adequate protection against future cerebral events. Furthermore, most patients with neurologic manifestations do not have echocardiographic evidence of thrombus on the lead. Conversely, presence of thrombus is highly associated with neurologic symptoms. Any intraarterial lead must be removed due to inevitable complications. Patients who have remained completely asymptomatic for > or = 3 years may be followed carefully with no therapy. For asymptomatic patients diagnosed before this time period, we recommend empiric therapy with antiplatelet agents or low-dose warfarin (international normalized ratio 1.5-2) with careful observation for symptoms.
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Affiliation(s)
- M Sharifi
- Department of Medicine, Lutheran General Hospital, Park Ridge, Illinois, USA
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29
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Estrada-Quintero T, Kross DE, Gorcsan J. Identification of a malpositioned atrial pacemaker lead across a patent foramen ovale by transesophageal echocardiography. J Am Soc Echocardiogr 1995; 8:560-2. [PMID: 7546797 DOI: 10.1016/s0894-7317(05)80348-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Transesophageal echocardiography was used for defining the unusual left atrial location of a malpositioned atrial pacemaker lead. This malpositioning occurred in a 75-year-old woman who had a small atrial septal aneurysm and a patent foramen ovale. Neither the precise location of the pacemaker lead tip nor the course of the lead was apparent by radiographic or transthoracic echocardiographic techniques. This report extends the potential utility of transesophageal echocardiography for the identification of malpositioned atrial pacemaker leads.
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30
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Cox JN. Pathology of cardiac pacemakers and central catheters. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 1994; 86:199-271. [PMID: 8162711 DOI: 10.1007/978-3-642-76846-0_6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- J N Cox
- Department of Pathology, CMU, Geneva, Switzerland
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Ghani M, Thakur RK, Boughner D, Morillo CA, Yee R, Klein GJ. Malposition of transvenous pacing lead in the left ventricle. Pacing Clin Electrophysiol 1993; 16:1800-7. [PMID: 7692412 DOI: 10.1111/j.1540-8159.1993.tb01814.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Malposition of pacemaker leads has been described in several locations but rarely in the left ventricle. The incidence and clinical course of this pacemaker complication are unknown. We describe clinical, electrocardiographic, chest X ray, and echocardiographic findings in four patients in whom the transvenous pacing lead was inadvertently placed through the interatrial septum and mitral valve into the left ventricle. In these patients, lead misplacement was not recognized at the time of implantation and lead malposition was diagnosed a mean of 2 years later. All four patients had right bundle branch block configuration paced complexes. In retrospect, chest X rays suggested atypical lead position in all, but the initial posterior-anterior and lateral chest X rays were misinterpreted and contributed to the delay in diagnosis. When lead misplacement in the left ventricle was considered it was confirmed by two-dimensional echocardiography. One patient subsequently presented with a stroke and the remainder were diagnosed when they presented with other unrelated problems. Pacing thresholds were normal at the time of implantation and behaved normally during follow-up. The patient presenting with stroke was anticoagulated and the other three have been managed expectantly without anticoagulation. Diagnosis of left ventricular lead malposition is not difficult but requires a high index of suspicion. A 12-lead ECG and posterior-anterior and lateral chest X rays after implantation can be diagnostic. Patients with pacing lead in the left ventricle may remain asymptomatic with normal lead function during long-term follow-up. Anticoagulation should be considered when this problem comes to attention for the first time during follow-up.
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Affiliation(s)
- M Ghani
- Department of Medicine, University of Western Ontario, London, Canada
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