Pacemaker leads and cardiac perforation

Navigating Complications in Cardiac Pacemakers: A Comprehensive Review and Management Strategies

The landscape of cardiac pacemaker technology has undergone significant evolution over the last two decades, transitioning from simple single-chamber devices to sophisticated multi-chamber rate-responsive systems and cardioverter defibrillators. This progression has introduced a complex array of complications inherent to device implantation and operation, encompassing both mechanical and clinical challenges. These complications notably include lead dislodgment, device migration, venous thrombosis, and hemothorax, which not only affect patient outcomes but also impose substantial economic burdens. This review meticulously analyzes these complications, elucidating their mechanisms, clinical implications, and the economic consequences associated with their management. It also outlines current and emerging strategies aimed at mitigating these complications, emphasizing the need for continual updates in clinical practices and protocols. Through this discourse, the review seeks to equip clinicians with a comprehensive understanding of these complications, thereby enhancing the safety and efficacy of cardiac pacing interventions.

Crossed my heart, into the gut? A case of cardiac perforation with accompanying diaphragmatic perforation during temporary transvenous pacemaker placement

Temporary transvenous pacing is generally considered a safe procedure and is commonly performed for various emergent indications. However, complications are quite common with minor complications being more frequent than major life-threatening events. Cardiac perforation is a serious complication associated with the procedure with possible life- threatening consequences. Our report describes the imaging findings in a rare case of cardiac perforation with accompanying diaphragmatic perforation during temporary transvenous pacemaker placement.

Ventricular tachyarrhythmia treatment and prevention by subthreshold stimulation with stretchable epicardial multichannel electrode array

The implantable cardioverter-defibrillator (ICD) is an effective method to prevent sudden cardiac death in high-risk patients. However, the transvenous lead is incompatible with large-area electrophysiological mapping and cannot accommodate selective multichannel precision stimulations. Moreover, it involves high-energy shocks, resulting in pain, myocardial damage, and recurrences of ventricular tachyarrhythmia (VTA). We present a method for VTA treatment based on subthreshold electrical stimulations using a stretchable epicardial multichannel electrode array, which does not disturb the normal contraction or electrical propagation of the ventricle. In rabbit models with myocardial infarction, the infarction was detected by mapping intracardiac electrograms with the stretchable epicardial multichannel electrode array. Then, VTAs could be terminated by sequential electrical stimuli from the epicardial multichannel electrode array beginning with low-energy subthreshold stimulations. Last, we used these subthreshold stimulations to prevent the occurrence of additional VTAs. The proposed protocol using the stretchable epicardial multichannel electrode array provides opportunities toward the development of innovative methods for painless ICD therapy.

More Than Skin Deep: An Unusual Case of a Migrating Pacemaker Lead

Pacemakers are commonly utilized in clinical practice and are generally well tolerated; therefore, clinicians may not be exposed to potential complications associated with pacemakers. This case report aims to illustrate the clinical presentation of a pacemaker lead migration, an uncommon potential complication. We present an 83-year-old male with a past medical history of complete atrioventricular block managed with a permanent pacemaker who presented with an open wound on his right chest. He had capped, abandoned right-sided leads from a previous pacemaker. At presentation, there was blood-tinged, yellow drainage and visible erosion of his electrodes. Computed tomography showed the right ventricular pacing lead perforating the right ventricle. Pacemaker lead migration outside of the chest wall is rare. Perforations may present asymptomatically or strikingly with effusions, pneumothoraces, hemothoraces, or cardiac tamponade. Management options include lead repositioning or extraction.

A Review of the Recent Advances of Cardiac Pacemaker Technology in Handling Complications

The total number of annual pacemaker implantations continues to grow globally, and help patients with heart rhythm disorders with an improved quality of life and reduced mortality. The first implantable pacemakers appeared in 1965, characterized by their bulkiness, short battery life, and a single pacing mode. Innovation led to the modern pacemaker: a smaller system with improved battery life and capacity, and innovation in lead technology. Certain arrhythmia conditions may also qualify for leadless pacemaker implantation, thus eliminating the spectrum of complications that could occur with leads. Adverse events can be divided into acute (perforation, lead dislodgement, infection) and long-term (lead fractures, device infection, insulation failure). Traditional long-term complications with leads occur in 10% of patients, compared with device-related adverse effects observed in 6.7% of leadless pacemakers. Furthermore, cardiac pacemaker implantation results in quality of life improvements across all age groups. Large cardiac rehabilitation studies have demonstrated the effectiveness of exercise in reducing the physical complications involved with pacemaker implantation. Of the three randomized controlled trials examined, all of them reported some benefit of exercise in the intervention group compared with the control. The following review aims to discuss the multitude of pacemaker options potentially available for the clinician, complications, their course of management, and the path forward with innovations arising out of previous research within the field.

Clinical profile and outcomes of semi-permanent pacing in a tertiary care institute in southern India

BACKGROUND

Semi-permanent pacing (SPP) includes the placement of a permanent lead through the internal jugular vein and connection to a pulse generator on the skin outside the venous access site.

AIM

To evaluate the clinical profile and outcomes of semi-permanent pacing in a tertiary care institute in Southern India.

METHODS

This is a retrospective observational study. All patients admitted and requiring management with semi-permanent pacing from January 2017 to June 2020 were included.

RESULTS

From January 2017 to June 2020, 20 patients underwent semi-permanent pacing (SPP) with a median age of 54 (21-74) years. Males comprised a majority of the patients (55%). Hypertension was noted in 50% of patients and 30% were diabetic. The right internal jugular vein was the most common access in 95% of patients. The most common indication for semi-permanent pacing was pocket site infection in 30% of patients. There were no procedural complications. The median duration on SPP was 7 (5-14) days and the median duration of hospital stay was 13 (8-21) days. Permanent pacemaker implantation was done in 55% of patients. Mortality in our study group was 15% with 10% dying due to cardiogenic shock (post resuscitated cardiac arrest) and 5% dying due to non-cardiac cause (Epidural hematoma).

CONCLUSION

In our study, semi-permanent pacing was noted to be a safe procedure and was more commonly indicated in emergent conditions with complete heart block secondary to underlying reversible causes and in the management of pocket site infection.

Delayed presentation of right ventricular lead perforation following defibrillator implantation: a case report

Background

Perforation of a device lead through the myocardium is a recognized complication of cardiac device implantation. The associated morbidity and mortality are significant, even though it is a relatively rare complication. Therefore, it is vital for acute clinicians to be aware of the diagnosis and subsequent management of myocardial perforation.

Case summary

We present the case of a 48-year-old woman who presented to the emergency department 1 month following implantable cardioverter-defibrillator implantation with chest and shoulder pain. Initial assessment revealed bilateral pleural effusions and anaemia. Computerized tomography of her chest and abdomen demonstrated a pericardial effusion, but it was transthoracic echocardiography that confirmed the diagnosis of right ventricular perforation. Urgent system revision was undertaken.

Discussion

This case highlights the importance of clinical suspicion and the use of diagnostic echocardiography as an important diagnostic tool in symptomatic patient’s post-cardiac device implantation.

Two episodes of cardiac tamponade in the same patient from removing pacing wires and a pericardial drain: A case report

A patient presented for an elective transcatheter aortic valve replacement with temporary transvenous pacing (TVP) wires placement per protocol. On postoperative day 1, the patient remained stable, so the wires were subsequently removed, after which the patient acutely decompensated, with transthoracic echocardiography revealing pericardial effusion. Emergent pericardiocentesis was performed, and a pericardial drain was placed. Three days later, the drain was removed; again, the patient acutely decompensated, requiring another emergent pericardiocentesis. Despite the relatively benign nature of TVP wires and pericardial drains, the possibility of cardiac tamponade should be kept in mind as a potential complication when they are being removed.