- Email: [email protected]
Very-late proarrhythmia of a migrant pacemaker lead
Available online at www.sciencedirect.com
Journal of Electrocardiology 44 (2011) 232 – 234 www.jecgonline.com
Very-late proarrhythmia of a migrant pacemaker lead Andreas Stein, a,⁎ Domenico Mazzitelli, b Christof Kolb a a
Deutsches Herzzentrum München und 1. Medizinische Klinik des Klinikum rechts der Isar, Faculty of Medicine, Technische Universität München, Munich, Germany b Klinik für Herzchirurgie, Deutsches Herzzentrum München, Faculty of Medicine, Technische Universität München, Munich, Germany Received 22 June 2010
Abstract
The report is on a 49-year-old patient who experienced life-threatening ventricular tachyarrhythmias caused by a pacemaker lead that was abandoned 26 years ago, migrated with its proximal ending to the main pulmonary artery and remained there asymptomatically for at least 3 years. © 2011 Elsevier Inc. All rights reserved.
Keywords:
Proarrhythmia; Migrant pacemaker lead
Case presentation We report on a 49-year-old patient admitted to hospital after preclinical resuscitation and defibrillation for ventricular fibrillation. On admission to the intensive care unit, the patient showed recurrent hemodynamically relevant ventricular tachycardia. Twelve-lead electrocardiogram of the arrhythmia demonstrated an inferior axis, a left bundle brunch pattern, and an R/S transition in leads V4 and V5, consistent with right ventricular outflow tract origin (Fig. 1). Chest x-ray showed pulmonary edema and a displaced pacemaker lead with no pacemaker implanted (Fig. 2A). Fluoroscopy revealed the pacemaker lead being migrated with the proximal end lying in the main pulmonary artery and the distal ending still in place in the right ventricular apex. Medical history taken from third party provided information that the patient had a severe car accident resulting in tetra paresis at the age of 18 years. At that time, a single-chamber pacemaker was implanted, presumably due to symptomatic bradycardia. Because the pacemaker was not required in the following 5 years, it was explanted and the ventricular lead was inactivated. Further workup of the patient's recent chest x-rays revealed that the pacemaker lead had migrated to the main pulmonary artery at least 3 years previously. Coronary artery disease was ruled out invasively, and electrolytes were within normal ranges; thus, mechanical irritation by the lead seemed to be the only remaining culprit ⁎ Corresponding author. Deutsches Herzzentrum München, Lazarettstrasse 36, 80636 München, Germany. E-mail addresses: [email protected], [email protected] 0022-0736/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jelectrocard.2010.08.002
for arrhythmia. Interventional extraction of the lead was attempted from the femoral vein, but failed. After catching the lead with a snare catheter, it was not possible to mobilize it due to complex adhesions at multiple sites in the main pulmonary artery. Therefore, a surgical approach was selected. Submammarian minithoracotomy at the level of the fourth right intercostal space was used for longitudinal arteriotomy of the pulmonary artery. The severely adhering lead was extracted, except for a small part that had been incorporated into the pulmonary artery wall (Fig. 2B). After removal of the lead, no further arrhythmias have been detected and the patient has remained event-free out to 17-month follow-up with absence of dizziness, palpitation, syncope, or presyncope.
Discussion The reported case describes an unusual course in a pacemaker recipient, in whom the generator box was explanted 26 years ago leaving the pacemaker lead in situ. Over the years, the pacemaker lead migrated to the main pulmonary artery without causing any symptoms or arrhythmias. Taking recent chest x-rays and the strong adhesions of the migrated lead to the vessel wall into account, it may be assumed that the lead remained in the main pulmonary artery for a considerable number of years without causing any problems to the patient. To the best of our knowledge, this is the first report of life-threatening arrhythmia due to a migrated pacemaker lead after such a long time. There may be doubts whether a true indication for permanent pacemaker placement was present at the time of
A. Stein et al. / Journal of Electrocardiology 44 (2011) 232–234
233
Fig. 1. (A) Monitor print out of a ventricular tachycardia. Arterial pressure, which is displayed in line 2, demonstrates hemodynamic instability. (B) Surface electrocardiogram documentation of a monomorphic ventricular tachycardia originating from the right ventricular outflow tract.
implantation 31 years ago. Unfortunately, no detailed reports on the indication could be retrieved from the implanting center. It may be speculated that the buried lead may not have been properly fixed in the pocket, that the fixation sutures may have loosened over time, or that in a failed extraction attempt, the lead may have remained floating in the vascular system. Whatever cause for lead migration is postulated, in clinical practice, there are patients who present with chronically dislodged or migrated leads who require decision making on whether or not to remove the electrode. Interventional and surgical lead removal is associated with risks that include potentially lethal complications.1-4 These
risks have to be weighed against the potential risks of retained leads that include lead migration and perforation. Furthermore, a retained lead may also represent a substrate facilitating thrombus and vegetation formation.5,6 Although watchful waiting is warranted in asymptomatic patients,7 even years of asymptomatic migration of an electrode does not guarantee continued freedom from arrhythmias and lifethreatening complications. In conclusion, migration of abandoned leads to the main pulmonary artery may occur without causing any symptoms for a very long period of time, and mechanically induced ventricular tachyarrhythmias can unexpectedly emerge requiring surgical removal of the lead.
234
A. Stein et al. / Journal of Electrocardiology 44 (2011) 232–234
Fig. 2. (A) Chest x-ray on admission demonstrating the migrated pacemaker lead. (B) Chest x-ray after surgical removal of the lead with remaining lead remnants.
References 1. Byrd CL, Wilkoff BL, Love CJ, et al. Intravascular extraction of problematic or infected permanent pacemaker leads: 1994-1996. U.S. Extraction Database, MED Institute. Pacing Clin Electrophysiol 1999;22:1348. 2. Jones SOT, Eckart RE, Albert CM, Epstein LM. Large, single-center, single-operator experience with transvenous lead extraction: outcomes and changing indications. Heart Rhythm 2008;5:520. 3. Kennergren C, Bjurman C, Wiklund R, Gabel J. A single-centre experience of over one thousand lead extractions. Europace 2009;11:612. 4. Hauser RG, Katsiyiannis WT, Gornick CC, Almquist AK, Kallinen LM. Deaths and cardiovascular injuries due to device-assisted implantable
cardioverter-defibrillator and pacemaker lead extraction. Europace 2010; 12:395. 5. Bohm A, Pinter A, Duray G, et al. Complications due to abandoned noninfected pacemaker leads. Pacing Clin Electrophysiol 2001;24: 1721. 6. Rozmus G, Daubert JP, Huang DT, Rosero S, Hall B, Francis C. Venous thrombosis and stenosis after implantation of pacemakers and defibrillators. J Interv Card Electrophysiol 2005;13:9. 7. Wilkoff BL, Love CJ, Byrd CL, et al. 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.
Journal of Electrocardiology 44 (2011) 232 – 234 www.jecgonline.com
Very-late proarrhythmia of a migrant pacemaker lead Andreas Stein, a,⁎ Domenico Mazzitelli, b Christof Kolb a a
Deutsches Herzzentrum München und 1. Medizinische Klinik des Klinikum rechts der Isar, Faculty of Medicine, Technische Universität München, Munich, Germany b Klinik für Herzchirurgie, Deutsches Herzzentrum München, Faculty of Medicine, Technische Universität München, Munich, Germany Received 22 June 2010
Abstract
The report is on a 49-year-old patient who experienced life-threatening ventricular tachyarrhythmias caused by a pacemaker lead that was abandoned 26 years ago, migrated with its proximal ending to the main pulmonary artery and remained there asymptomatically for at least 3 years. © 2011 Elsevier Inc. All rights reserved.
Keywords:
Proarrhythmia; Migrant pacemaker lead
Case presentation We report on a 49-year-old patient admitted to hospital after preclinical resuscitation and defibrillation for ventricular fibrillation. On admission to the intensive care unit, the patient showed recurrent hemodynamically relevant ventricular tachycardia. Twelve-lead electrocardiogram of the arrhythmia demonstrated an inferior axis, a left bundle brunch pattern, and an R/S transition in leads V4 and V5, consistent with right ventricular outflow tract origin (Fig. 1). Chest x-ray showed pulmonary edema and a displaced pacemaker lead with no pacemaker implanted (Fig. 2A). Fluoroscopy revealed the pacemaker lead being migrated with the proximal end lying in the main pulmonary artery and the distal ending still in place in the right ventricular apex. Medical history taken from third party provided information that the patient had a severe car accident resulting in tetra paresis at the age of 18 years. At that time, a single-chamber pacemaker was implanted, presumably due to symptomatic bradycardia. Because the pacemaker was not required in the following 5 years, it was explanted and the ventricular lead was inactivated. Further workup of the patient's recent chest x-rays revealed that the pacemaker lead had migrated to the main pulmonary artery at least 3 years previously. Coronary artery disease was ruled out invasively, and electrolytes were within normal ranges; thus, mechanical irritation by the lead seemed to be the only remaining culprit ⁎ Corresponding author. Deutsches Herzzentrum München, Lazarettstrasse 36, 80636 München, Germany. E-mail addresses: [email protected], [email protected] 0022-0736/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jelectrocard.2010.08.002
for arrhythmia. Interventional extraction of the lead was attempted from the femoral vein, but failed. After catching the lead with a snare catheter, it was not possible to mobilize it due to complex adhesions at multiple sites in the main pulmonary artery. Therefore, a surgical approach was selected. Submammarian minithoracotomy at the level of the fourth right intercostal space was used for longitudinal arteriotomy of the pulmonary artery. The severely adhering lead was extracted, except for a small part that had been incorporated into the pulmonary artery wall (Fig. 2B). After removal of the lead, no further arrhythmias have been detected and the patient has remained event-free out to 17-month follow-up with absence of dizziness, palpitation, syncope, or presyncope.
Discussion The reported case describes an unusual course in a pacemaker recipient, in whom the generator box was explanted 26 years ago leaving the pacemaker lead in situ. Over the years, the pacemaker lead migrated to the main pulmonary artery without causing any symptoms or arrhythmias. Taking recent chest x-rays and the strong adhesions of the migrated lead to the vessel wall into account, it may be assumed that the lead remained in the main pulmonary artery for a considerable number of years without causing any problems to the patient. To the best of our knowledge, this is the first report of life-threatening arrhythmia due to a migrated pacemaker lead after such a long time. There may be doubts whether a true indication for permanent pacemaker placement was present at the time of
A. Stein et al. / Journal of Electrocardiology 44 (2011) 232–234
233
Fig. 1. (A) Monitor print out of a ventricular tachycardia. Arterial pressure, which is displayed in line 2, demonstrates hemodynamic instability. (B) Surface electrocardiogram documentation of a monomorphic ventricular tachycardia originating from the right ventricular outflow tract.
implantation 31 years ago. Unfortunately, no detailed reports on the indication could be retrieved from the implanting center. It may be speculated that the buried lead may not have been properly fixed in the pocket, that the fixation sutures may have loosened over time, or that in a failed extraction attempt, the lead may have remained floating in the vascular system. Whatever cause for lead migration is postulated, in clinical practice, there are patients who present with chronically dislodged or migrated leads who require decision making on whether or not to remove the electrode. Interventional and surgical lead removal is associated with risks that include potentially lethal complications.1-4 These
risks have to be weighed against the potential risks of retained leads that include lead migration and perforation. Furthermore, a retained lead may also represent a substrate facilitating thrombus and vegetation formation.5,6 Although watchful waiting is warranted in asymptomatic patients,7 even years of asymptomatic migration of an electrode does not guarantee continued freedom from arrhythmias and lifethreatening complications. In conclusion, migration of abandoned leads to the main pulmonary artery may occur without causing any symptoms for a very long period of time, and mechanically induced ventricular tachyarrhythmias can unexpectedly emerge requiring surgical removal of the lead.
234
A. Stein et al. / Journal of Electrocardiology 44 (2011) 232–234
Fig. 2. (A) Chest x-ray on admission demonstrating the migrated pacemaker lead. (B) Chest x-ray after surgical removal of the lead with remaining lead remnants.
References 1. Byrd CL, Wilkoff BL, Love CJ, et al. Intravascular extraction of problematic or infected permanent pacemaker leads: 1994-1996. U.S. Extraction Database, MED Institute. Pacing Clin Electrophysiol 1999;22:1348. 2. Jones SOT, Eckart RE, Albert CM, Epstein LM. Large, single-center, single-operator experience with transvenous lead extraction: outcomes and changing indications. Heart Rhythm 2008;5:520. 3. Kennergren C, Bjurman C, Wiklund R, Gabel J. A single-centre experience of over one thousand lead extractions. Europace 2009;11:612. 4. Hauser RG, Katsiyiannis WT, Gornick CC, Almquist AK, Kallinen LM. Deaths and cardiovascular injuries due to device-assisted implantable
cardioverter-defibrillator and pacemaker lead extraction. Europace 2010; 12:395. 5. Bohm A, Pinter A, Duray G, et al. Complications due to abandoned noninfected pacemaker leads. Pacing Clin Electrophysiol 2001;24: 1721. 6. Rozmus G, Daubert JP, Huang DT, Rosero S, Hall B, Francis C. Venous thrombosis and stenosis after implantation of pacemakers and defibrillators. J Interv Card Electrophysiol 2005;13:9. 7. Wilkoff BL, Love CJ, Byrd CL, et al. 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.