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Delayed myocardial perforation following pacemaker implantation
International Journal of Cardiology 93 (2004) 89 – 91 www.elsevier.com/locate/ijcard
Letter to the Editor
Delayed myocardial perforation following pacemaker implantation Vicente Barriales Alvarez a,*, Jose´ A. Alvarez Tamargo a, Marcos Garcı´a Aguado a, Marı´a Martı´n Ferna´ndez a, Carlos Morales b b
a Service of Cardiology, Central Hospital of Asturias, C/. Julia´n Claverı´a s/n, 33006, Oviedo, Spain Service of Cardiac Surgery, Central Hospital of Asturias, C/. Julia´n Claverı´a s/n, 33006, Oviedo, Spain
Received 10 October 2002; accepted 29 January 2003
Abstract Myocardial perforation is a rare complication following pacemaker implantation that may cause cardiac tamponade. If it does occur, it is usually at the time of lead insertion. This condition requires urgent recognition since the prompt drainage of the pericardial fluid may be lifesaving. We present a case report of myocardial perforation complicated by cardiac tamponade 4 days after pacemaker lead insertion that was repaired surgically. D 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiac tamponade; Pacemaker
Myocardial perforation is a rare complication [1] following pacemaker implantation with contemporary leads. Perforation may produce pericardial pain or no symptoms at all. It may cause intermittent or complete failure of pacing or diaphragmatic stimulation. Cardiac tamponade is uncommon; if it happens, it is usually at the time of lead insertion and rarely after the first 24 h [2]. A case of myocardial perforation complicated by cardiac tamponade after pacemaker lead insertion is reported. A 53-year-old man with a history of syncope and probable severe aortic stenosis was admitted to hospital for further assessment. A complete AV block with pauses of 3 s was registered while monitoring. The diagnosis of severe aortic stenosis was confirmed by echocardiogram. The patient had an excellent functional capacity, and a DDDR cardiac pacemaker was implanted. Ventricular lead had to be withdrawn and repositioned because of diaphragmatic stimulation at the time of implantation. Three days later, the patient was asymptomatic and hemodynamically stable so he was discharged. Twelve hours
* Corresponding author. Tel.: +34-98-510-8000x36261; fax: +34-98527-4688. E-mail address: [email protected] (V. Barriales Alvarez). 0167-5273/$ - see front matter D 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0167-5273(03)00129-3
after discharge, he went to the Emergency Department with pericardial pain. Pulsus paradoxus and friction rub were not present. The ECG showed ST segment changes and alternation of amplitude of the QRS complex (Fig. 1). Echocardiography demonstrated a large pericardial effusion with signs of cardiac tamponade (Fig. 2). A pericardiocentesis confirmed the diagnosis of hemopericardium due to myocardial perforation and cardiac surgery was carried out urgently. A perforation of the apex of the left ventricle next to the interventricular septum was found and the aortic valve was replaced with a mechanical prosthetic valve. Cardiac perforation is a serious and often unrecognized complication of pacemaker lead insertion. After implantation, it may be recognized by pericardial pain, friction rub, diaphragmatic stimulation, pericardial effusion or increasing ventricular pacing threshold. The presence of a right bundle branch block pattern with pacing could be a sign of perforation [2]. Cardiac tamponade due to lead insertion is exceptional with the use of current leads in the absence of anticoagulation. If it happens, it is usually at the time of lead implantation [1]. When cardiac perforation is suspected at this time, an echocardiogram should be performed and the lead must be withdrawn and repositioned under careful observation. If the patient is hemodynamically stable, clinical observation is
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V. Barriales Alvarez et al. / International Journal of Cardiology 93 (2004) 89–91
Fig. 1. ECG recording after the development of pericardial pain showing ST segment changes and QRS electrical alternans.
the usual recommendation [3]. Although some cases have been reported [4,5], the development of cardiac tamponade as a complication following lead insertion is rare after the first 24 h of pacemaker implantation. Pericardiocentesis should be performed in this situation to improve the hemodynamic of the patient and to confirm the presence of hemopericardium.
Hemopericardium secondary to myocardial perforation is likely to recur after pericardiocentesis so this procedure should be used only as a temporary measure prior to surgical intervention [6]. Surgical exploration should include the left ventricle because the lead can migrate to it through the interventricular septum as happened in this case.
V. Barriales Alvarez et al. / International Journal of Cardiology 93 (2004) 89–91
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Fig. 2. Parasternal short-axis view showed a large pericardial effusion.
References [1] Trigano JA, Paganelli F, Ricard P, Ferraci A, Avierinos JF, Levy S. Heart perforation following transvenous implantation of a cardiac pacemaker. Presse Med 1999;28(16):836 – 40. [2] Mitriani RD, Myeburg RJ, Castellanos A. Cardiac pacemakers. In: Alexander RW, Schlant RC, Fuster V, editors. 9th ed., Hurt’s the heart, vol. 1. New York: McGraw-Hill; 1998. p. 1023 – 55. [3] Asano M, Mishima A, Ishii T, Takeuchi Y, Suzuki Y, Manabe T. Surgical treatment for right ventricular perforation caused by transve-
nous pacing electrodes: a report of three cases. Surg Today 1996; 26(1):933 – 5. [4] Gershon T, Kuruppu J, Olshaker J. Delayed cardiac tamponade after pacemaker insertion. J Emerg Med 2000;18(3):355 – 9. [5] Spindler M, Burrows G, Kowallik P, Ertl G, Voelker W. Postpericardiotomy syndrome and cardiac tamponade as a late complication after pacemaker implantation. Pacing Clin Electrophysiol 2001;24(9): 1433 – 4. [6] Lorell BH. Pericardial diseases. In: Brunwald E, editor. Heart disease. A textbook of cardiovascular medicine. Philadelphia, PA: Saunders; 1997. p. 1478 – 534.
Letter to the Editor
Delayed myocardial perforation following pacemaker implantation Vicente Barriales Alvarez a,*, Jose´ A. Alvarez Tamargo a, Marcos Garcı´a Aguado a, Marı´a Martı´n Ferna´ndez a, Carlos Morales b b
a Service of Cardiology, Central Hospital of Asturias, C/. Julia´n Claverı´a s/n, 33006, Oviedo, Spain Service of Cardiac Surgery, Central Hospital of Asturias, C/. Julia´n Claverı´a s/n, 33006, Oviedo, Spain
Received 10 October 2002; accepted 29 January 2003
Abstract Myocardial perforation is a rare complication following pacemaker implantation that may cause cardiac tamponade. If it does occur, it is usually at the time of lead insertion. This condition requires urgent recognition since the prompt drainage of the pericardial fluid may be lifesaving. We present a case report of myocardial perforation complicated by cardiac tamponade 4 days after pacemaker lead insertion that was repaired surgically. D 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiac tamponade; Pacemaker
Myocardial perforation is a rare complication [1] following pacemaker implantation with contemporary leads. Perforation may produce pericardial pain or no symptoms at all. It may cause intermittent or complete failure of pacing or diaphragmatic stimulation. Cardiac tamponade is uncommon; if it happens, it is usually at the time of lead insertion and rarely after the first 24 h [2]. A case of myocardial perforation complicated by cardiac tamponade after pacemaker lead insertion is reported. A 53-year-old man with a history of syncope and probable severe aortic stenosis was admitted to hospital for further assessment. A complete AV block with pauses of 3 s was registered while monitoring. The diagnosis of severe aortic stenosis was confirmed by echocardiogram. The patient had an excellent functional capacity, and a DDDR cardiac pacemaker was implanted. Ventricular lead had to be withdrawn and repositioned because of diaphragmatic stimulation at the time of implantation. Three days later, the patient was asymptomatic and hemodynamically stable so he was discharged. Twelve hours
* Corresponding author. Tel.: +34-98-510-8000x36261; fax: +34-98527-4688. E-mail address: [email protected] (V. Barriales Alvarez). 0167-5273/$ - see front matter D 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0167-5273(03)00129-3
after discharge, he went to the Emergency Department with pericardial pain. Pulsus paradoxus and friction rub were not present. The ECG showed ST segment changes and alternation of amplitude of the QRS complex (Fig. 1). Echocardiography demonstrated a large pericardial effusion with signs of cardiac tamponade (Fig. 2). A pericardiocentesis confirmed the diagnosis of hemopericardium due to myocardial perforation and cardiac surgery was carried out urgently. A perforation of the apex of the left ventricle next to the interventricular septum was found and the aortic valve was replaced with a mechanical prosthetic valve. Cardiac perforation is a serious and often unrecognized complication of pacemaker lead insertion. After implantation, it may be recognized by pericardial pain, friction rub, diaphragmatic stimulation, pericardial effusion or increasing ventricular pacing threshold. The presence of a right bundle branch block pattern with pacing could be a sign of perforation [2]. Cardiac tamponade due to lead insertion is exceptional with the use of current leads in the absence of anticoagulation. If it happens, it is usually at the time of lead implantation [1]. When cardiac perforation is suspected at this time, an echocardiogram should be performed and the lead must be withdrawn and repositioned under careful observation. If the patient is hemodynamically stable, clinical observation is
90
V. Barriales Alvarez et al. / International Journal of Cardiology 93 (2004) 89–91
Fig. 1. ECG recording after the development of pericardial pain showing ST segment changes and QRS electrical alternans.
the usual recommendation [3]. Although some cases have been reported [4,5], the development of cardiac tamponade as a complication following lead insertion is rare after the first 24 h of pacemaker implantation. Pericardiocentesis should be performed in this situation to improve the hemodynamic of the patient and to confirm the presence of hemopericardium.
Hemopericardium secondary to myocardial perforation is likely to recur after pericardiocentesis so this procedure should be used only as a temporary measure prior to surgical intervention [6]. Surgical exploration should include the left ventricle because the lead can migrate to it through the interventricular septum as happened in this case.
V. Barriales Alvarez et al. / International Journal of Cardiology 93 (2004) 89–91
91
Fig. 2. Parasternal short-axis view showed a large pericardial effusion.
References [1] Trigano JA, Paganelli F, Ricard P, Ferraci A, Avierinos JF, Levy S. Heart perforation following transvenous implantation of a cardiac pacemaker. Presse Med 1999;28(16):836 – 40. [2] Mitriani RD, Myeburg RJ, Castellanos A. Cardiac pacemakers. In: Alexander RW, Schlant RC, Fuster V, editors. 9th ed., Hurt’s the heart, vol. 1. New York: McGraw-Hill; 1998. p. 1023 – 55. [3] Asano M, Mishima A, Ishii T, Takeuchi Y, Suzuki Y, Manabe T. Surgical treatment for right ventricular perforation caused by transve-
nous pacing electrodes: a report of three cases. Surg Today 1996; 26(1):933 – 5. [4] Gershon T, Kuruppu J, Olshaker J. Delayed cardiac tamponade after pacemaker insertion. J Emerg Med 2000;18(3):355 – 9. [5] Spindler M, Burrows G, Kowallik P, Ertl G, Voelker W. Postpericardiotomy syndrome and cardiac tamponade as a late complication after pacemaker implantation. Pacing Clin Electrophysiol 2001;24(9): 1433 – 4. [6] Lorell BH. Pericardial diseases. In: Brunwald E, editor. Heart disease. A textbook of cardiovascular medicine. Philadelphia, PA: Saunders; 1997. p. 1478 – 534.