An unusual case of multiple right atrial thrombi in a patient with a dual-chamber pacemaker--a case report

Georgia G, Athanasios KI. Case report: recurrent thrombosis of an old lead of a DDDR pacemaker mimicking lead infection

Introduction

Thrombosis of the intracardiac part of a permanent pacemaker lead, which is usually detected during a routine transthoracic echocardiographic examination, can be totally asymptomatic. The differential diagnosis between intracardiac lead thrombosis and vegetation is crucial, especially in febrile patients, as these two situations are totally different regarding prognosis and treatment.

Case presentation

We describe the case of an 85-year-old patient with a dual chamber pacemaker (DDDR) due to complete heart block, who was admitted twice, within 2 years, with vegetation-like masses attached to the ventricular lead of the pacemaker. Infective endocarditis was not documented (diagnostic criteria were not fulfilled), although clinical suspicion was high during both hospitalizations. Masses resolved under applied treatment (anticoagulation) in both cases.

Discussion

Differential diagnosis between lead thrombosis and vegetation was ambiguous in both hospitalizations. Τhe ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography during the 2nd hospitalization excluded a possible inflammatory origin of the masses.

Echocardiography in patients with complications related to pacemakers and cardiac defibrillators

The evolving indications and uses for implantable cardiac devices have led to a significant increase in the number of implanted devices each year. Implantation of endocardial leads for permanent pacemakers and cardiac defibrillators can cause many delayed complications. Complications may be mechanical and related to the interaction of the device leads with the valves and endomyocardium, e.g., perforation, infection, and thrombosis, or due to the electrical pacing of the myocardium and conduction abnormalities, e.g., left ventricular dyssynchrony. Tricuspid regurgitation, another delayed complication in these patients, may be secondary to both mechanical and pacing effects of the device leads. Echocardiography plays an important role in the diagnosis of these device-related complications. Both two-dimensional transthoracic echocardiography and transesophageal echocardiography provide useful diagnostic information. Real time three-dimensional echocardiography is a novel technique that can further enhance the detection of lead-related complications.

The first three-dimensional visualization of a thrombus in transit trapped between the leads of a permanent dual-chamber pacemaker: a case report

Introduction

Two-dimensional echocardiography is a useful tool in diagnosing cardiac masses. However, the three-dimensional offline reconstruction technique of transesophageal echocardiography might be superior to two-dimensional transesophageal echocardiography in providing additional information of structural details.

Case presentation

We report the case of a 76-year-old Caucasian man with a permanent dual-chamber pacemaker and a worm-like right-heart thrombus in transit. Two-dimensional transthoracic echocardiography and two-dimensional transesophageal echocardiography showed that it was debatable as to whether "the worm" was originating from the leads. Offline three-dimensional transesophageal echocardiography reconstruction technique proved superior in identifying the cardiac mass as a thrombus trapped between the leads of the pacemaker. The thrombus was successfully dissolved by systemic heparin therapy.

Conclusions

The three-dimensional transesophageal echocardiography is useful and effective in patients with implanted pacemakers or defibrillators when other closely competing imaging modalities are contraindicated, such as magnetic resonance imaging. In patients with pacemakers and trapped thrombus in transit for whom surgical therapy might be a high risk, medical therapy seems to offer a safer and convincing alternative. Whether the management of right-heart thrombi has to be modified due to the presence of pacemaker leads is controversial.

Right atrial thrombus secondary to pacemaker wires

BACKGROUND

Pacemaker-induced right atrial thrombus is a rare condition that has not been described in the Emergency Medicine literature. This is a potentially fatal condition that is diagnosed with an echocardiogram and treated with surgical removal, thrombolytics, or long-term anticoagulation.

OBJECTIVES

This case report is designed to increase awareness among emergency physicians of this potentially fatal condition.

CASE REPORT

We describe the case of a patient with a massive right atrial thrombus secondary to pacemaker wire who presented to the Emergency Department with syncope, bradycardia, and rapid hemodynamic deterioration.

CONCLUSION

Emergency physicians should be aware of this life-threatening entity. Emergency bedside cardiac ultrasound or echocardiogram may be of value in its early identification.

Right atrial pacemaker lead thrombosis causing tricuspid inflow obstruction

A 75-year-old man was admitted to our hospital with a complaint of progressive dyspnea with effort. The patient had a permanent pacemaker that was implanted 16 years ago. Transesophageal echocardiography revealed a large, mobile mass in the right atrium attaching to the insertion site of the atrial lead at the tricuspid valve level. Because of the size, mobility, and location of the mass, urgent surgical removal was considered. The mass was successfully removed. Histologic examination of the mass demonstrated a partially organized thrombus. The postoperative course was uneventful and the patient's symptoms improved remarkably after operation.

Pacemaker lead thrombosis treated with atrial thrombectomy and biventricular pacemaker and defibrillator insertion

Right atrial thrombosis and pulmonary embolism are infrequent complications of pacemaker insertion. We report a patient with a large mobile thrombus on an endocardial DDD pacing lead and probable pulmonary embolism. We believe that this is the first case of pacemaker lead thrombosis in which treatment included insertion of an epicardial biventricular pacemaker and an implantable cardioverter-defibrillator.

Early Pacemaker Lead Thrombosis Leading to Massive Pulmonary Embolism

Clinically apparent pulmonary embolism is a rare complication of permanent transvenous pacing catheters. Here we report an unusual case of a 71-year-old man who developed massive pulmonary embolism 12 hours after a permanent transvenous pacemaker implantation in the absence of any patient-related predisposing factor. Transesophageal echocardiography showed a large thrombus within the right atrium closely attached to the pacemaker lead. Anticoagulation with heparin, followed by warfarin therapy, led to a complete resolution of the thrombus.

Intra-atrial thrombosis and pulmonary embolism complicating pacemaker leads for cardiac resynchronization therapy

This is the first report of intracardiac thrombi and pulmonary embolism complicating pacemaker leads implanted for cardiac resynchronization therapy. Prompt diagnosis and successful therapy with a thrombolytic agent lead to a favourable outcome. This report suggests that long-term oral anticoagulation should be considered in patients with depressed left ventricular function undergoing cardiac resynchronization therapy in order to prevent this potentially serious complication.