Pulmonary Artery Intimal Sarcoma Mimicking Right Ventricular Outflow Tract Thrombus

A 72-year-old man presented with breathlessness and a systolic murmur. Extensive diagnostic work-up revealed a rare pulmonary artery intimal sarcoma mimicking a right ventricular outflow tract thrombus and impacting a cardiac pacemaker lead. Surgical resection, pathology confirmation, and management strategies are discussed, highlighting the challenges of treating this rare malignancy.

Tailored Treatment of Patients With Intracardiac Leads and Tricuspid Regurgitation

Tricuspid regurgitation (TR) is frequent in patients with leads from rhythm control devices. Percutaneous treatment of TR can be an effective therapy in these patients but needs to be tailored based on valve anatomy and the underlying mechanism of the TR as shown in the case series that we present. (Level of Difficulty: Advanced.).

Is It Possible to Place a Pacemaker Lead Through a Bileaflet Mechanical Prosthesis?

We present a 64-year-old woman who underwent mitral, aortic, and tricuspid valve (TV) replacement with mechanical prostheses. Two months after TV surgery, she presented third-degree atrioventricular block. After attempting to place a pacemaker lead through the coronary sinus, it was placed through the mechanical valve in the tricuspid position as the last option. At 1 year of follow-up, the device shows no signs of dysfunction, and the prosthesis has moderate regurgitation.

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.

Evaluation of safety and feasibility of leadless pacemaker implantation following the removal of an infected pacemaker

BACKGROUND

Leadless pacemakers provide safe and effective pacing options for patients with device-related infections. This study was aimed at observing and evaluating the safety and feasibility of extracting an infected pacemaker device followed by the implantation of a leadless pacemaker in the same location for patients without systemic infection.

METHODS

Between December 2019 and September 2020, following a well-planned re-implantation strategy, pacemaker electrodes were removed from patients with device infection and leadless pacemakers were immediately implanted at our center. The patients were then followed up for up to 10 months to assess the safety and practicality of the procedure.

RESULTS

Pacemaker electrode removal and immediate leadless pacemaker implantation were successfully achieved in eight patients with pocket infection. After a minimum follow-up period of 1 month and a maximum follow-up of 10 months, the pacing parameters for the patients remained stable and there was no infection at the original capsular bag or in the leadless pacemaker.

CONCLUSION

Direct implantation of a leadless pacemaker is safe and feasible for patients with local infection of the pacing system after removal of the electrode as an alternative to a bridge period with a temporary pacemaker. This strategy may be a better option for pacing-dependent patients.

Predictors of lead break during transvenous lead extraction

BACKGROUND

The incidence, predictors, and clinical impact of lead break during transvenous lead extraction (TLE) were previously unknown.

METHODS

We included consecutive patients who underwent TLE between September 2013 and July 2019 at our institute. Lead break during removal was defined as lead stretching and becoming misshapen, as assessed by fluoroscopy.

RESULTS

A total of 246 patients underwent TLE for 501 leads. At a patient level, complete success was achieved in 226 patients (91.9%). At a lead level, 481 leads (96.0%) were completely removed and 101 leads (20.1%) were broken during the procedure. Of 392 identified pacemaker leads, 71 (18.3%) were broken during the TLE procedure. A multivariable analysis confirmed high lead age (odds ratio [OR] 1.12, 95% confidence interval (CI) 1.07-1.17; P < .001), passive leads (OR 2.29 95% CI 1.09-4.80; P = .028), coradial leads (OR 3.45 95% CI 1.72-6.92; P < .001), and insulators made of nonpolyurethane (OR 2.38 95% CI 1.03-5.26; P = .04) as predictors of lead break. Broken leads needed longer procedure times and were associated with a higher rate of cardiac tamponade.

CONCLUSIONS

Lead age, coradial bipolar leads, passive leads, and leads without polyurethane insulation were predictors of lead break and could increase the difficulty of lead extraction.

Unexpected pacemaker lead in an 84-year-old patient

An elderly patient with a history of atrial fibrillation presented to our emergency room. Previous medical records from another hospital described a pacemaker lead in the echocardiography although the patient had no known history of a pacemaker implantation. Finally, by close examination, chest X-ray, and computed tomography, we found that a kyphoplasty of the spine had caused a so-called palacos embolism, which had repeatedly been mistaken for a pacemaker lead. Unusually, there were no further signs of kyphoplasty material in the pulmonary veins. As the patient was asymptomatic and the embolism caused only moderate tricuspid regurgitation, a conservative treatment was agreed on.

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.

Flexible Energy Harvester on a Pacemaker Lead Using Multibeam Piezoelectric Composite Thin Films

Implantable medical devices, such as cardiac pacemakers and defibrillators, rely on batteries for operation. However, conventional batteries only last for a few years, and additional surgeries are needed for replacement. Harvesting energy directly from the human body enables a new paradigm of self-sustainable power sources for implantable medical devices without being constrained by the battery's limited lifetime. Here, we report the design of a multibeam cardiac energy harvester using polydimethylsiloxane (PDMS)-infilled microporous P(VDF-TrFE) composite films. We first added ZnO nanoparticles and multiwall carbon nanotubes into microporous P(VDF-TrFE) films to increase the energy output. The mixing ratios of 30% ZnO and 0.1% MWCNTs yielded 3.22 ± 0.24 V output, which resulted in a voltage output 46 times higher than that of pure P(VDF-TrFE) films. Next, we discovered that the voltage generated by the composite film with PDMS is approximately 105% higher than that of the one without PDMS. For the application in cardiac pacemakers, we developed a facile fabrication method by building a cylindrical multibeam device that resides on the pacemaker lead to harvest energy from the complex motion of the lead driven by the heartbeat. Since the energy harvesting component is integrated into the pacemaker, it significantly reduces the risks and expenses associated with pacemaker-related surgeries. This work paves the way toward the new generation of energy harvesters that will benefit patients with a variety of implantable biomedical devices.

Outcomes of repeated transvenous lead extraction

INTRODUCTION

The outcomes of repeated cardiovascular implantable electronic device (CIED) lead extraction have not been well studied. We sought to determine the indications, outcomes, and safety of repeated lead extraction procedures.

METHODS

This retrospective study was conducted using data from two medical centers, including 38 patients who had undergone two or more lead extraction procedures compared to 439 patients who had a single procedure. The electronic medical records and procedural databases were reviewed to determine the indications, procedural characteristics, and outcomes. The outcomes of the first procedure were compared to the outcomes of subsequent procedures.

RESULTS

The 5-year cumulative probability of a repeated extraction procedure was 11% (95% confidence interval, 7%-15%). In 439 patients who underwent single lead extractions, 72% had device and lead related infections as the procedure indication compared to 39% for 38 patients who underwent repeated extraction (P < 0.001). The mean duration from device reimplant to repeated extraction procedures was 63 ± 48 months. Ninety-eight percent of the leads were removed completely in repeated procedures, similar to the 95% success rate of the first procedure (P = 0.51). There was no significant difference in major complication rate in the first or repeated extractions (2.6% vs 5.2%, P = 0.79).

CONCLUSIONS

Repeated transvenous lead extraction is not uncommon. It had a high success rate comparable to that of the initial procedure and was not associated with an increased incidence of adverse events.

Balloon venoplasty opens the road for an implantable defibrillator patient with complex stenosis

There is an increasing need for physicians to handle venous obstructions in pacemaker/implantable cardioverter-defibrillator implants. Venoplasty performed by an experienced operator is a simple, safe, and fast way to manage this situation and proceed to implant. Compared to other approaches, this strategy may offer particular advantages.

How pacemakers work and simple programming: a primer for the non-electrophysiologist

Paediatric pacemaker management is challenging because of the small patient size, complex cardiac anatomy, and unique programming considerations. Hardware placement options include epicardial and transvenous systems. When pacemaker malfunction is suspected, a systematic approach is required to determine whether there is malfunction in pacing, sensing, or no output due to hardware problem. In most cases, simple reprogramming may circumvent the problem and allow retention of the pacemaker system.

Leadless Cardiac Pacemaker Implantation After Lead Extraction in Patients With Severe Device Infection

BACKGROUND

Conventional pacemaker therapy is limited by short- and long-term complications, most notably device infection. Transcatheter pacing systems (TPS) may be beneficial in this kind of patients as they eliminate the need for a device pocket and leads and thus may reduce the risk of re-infection.

METHODS

We assessed a novel procedure in 6 patients with severe device infection who were pacemaker dependent. After lead extraction a single chamber TPS was implanted into the right ventricle.

RESULTS

Of the 6 patients who underwent lead extraction due to severe device infection at our institution, 3 were diagnosed with a pocket infection only, whereas the other 3 showed symptoms of both pocket and lead infection. Successful lead extraction and TPS implantation was accomplished in all patients. Four patients were bridged with a temporary pacemaker between 2 hours and 2 days after lead extraction, whereas 2 patients had the TPS implanted during the same procedure just before traditional pacemaker system removal. All patients stayed free of infection during the follow-up period of 12 weeks. An additional positron emission tomography scan was performed in each patient and indicated no signs of an infection around the TPS.

CONCLUSION

Transcather pacemaker implantation was safe and feasible in 6 patients and did not result in re-infection even if implanted before removal of the infected pacemaker system within the same procedure. Therefore, implantation of a TPS may be an option for patients with severe device infection, especially in those with blocked venous access or who are pacemaker dependent.

Entire removal of screw-in pacing leads 3 years after implantation

Objective: To report that screw-in type pacing leads can be removed by screw retraction even after a significant anchoring period.

Patient: A 78-year-old woman who visited our hospital for skin erosion over a pacemaker that had been implanted 3 years previously and had migrated from the subclavicular area to the axilla.

Methods: Culture revealed a local staphylococcus infection. We placed a new pacemaker system in the contralateral (right) side, removed the old one, inserted a straight type stylet into the leads, and turned the rotator counterclockwise.

Results: An image monitor confirmed complete retraction of the ventricular lead screw and partial retraction of the atrial lead screw, and we were able to pull out both leads without any resistance. The patient was given antibiotics and discharged 2 days after the surgery. No wound infection was evident at a 3-month follow-up examination.

Conclusion: When a screw-in type pacemaker with a retractor must be removed long after its implantation, screw retraction should be tried before resorting to a removal kit or open heart surgery.