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Migration of epicardial pacemaker leads
Clin. Radiol. (1975) 26, 483-486
MIGRATION MURRAY
OF EPICARDIAL
WATNICK, t IRAJ HOOSHMAND
PACEMAKER and HUGO
LEADS*
SPINDOLA-FRANCO
Department of Radiology, Harvard Medical School and Peter Bent Brigham Hospital, Boston, Massachusetts, U.S.A. T h e i m p l a n t a t i o n of p e r m a n e n t p a c e m a k e r s often gives rise to complications. M i g r a t i o n o f leads, an unusual complication, occurred in two of our p a t i e n t s with epicardial pacemakers. I n one case lead fracture and subsequent d i s p l a c e m e n t due to h e a r t a c t i o n occurred after an a u t o m o b i l e accident. In the second case l o o p i n g a n d migration o f the wire occurred within a day after i m p l a n t a t i o n a l t h o u g h the lead continued to f u n c t i o n p r o p e r l y for six months. The p r o b a b l e cause o f m i g r a t i o n in this p a t i e n t was excess slack. IT is now over 20 years since Zoll published his clinical p a p e r on external electric stimulation o f the h e a r t (Zoll, 1952). N u m e r o u s technical advances have occurred since then a n d m o r e are on the horizon. C o m p l i c a t i o n s s e c o n d a r y to insertion o f foreign materials into the b o d y are inevitable. It is therefore n o t surprising that there are m a n y
reports o f c o m p l i c a t i o n s following the surgical i m p l a n t a t i o n o f p e r m a n e n t pacemakers. This r e p o r t describes two p a c e m a k e r patients with a unique u n r e p o r t e d complication.
* This work was supported in part by USPHS grants HLl1668 and HL05832. t Present address: Noble Hospital, 115 West Silver Street, Westfield, Massachussets 01085.
Case 1. - A 56-year-old white male was admitted to the hospital with congestive heart failure and pacemaker dysfunction. Six years previously, the patient had an epicardial pacemaker placed for complete heart block with Stokes-Adams attacks. The battery was changed three years later. Chest film at that time showed intact pacemaker wires (Fig. la). Approximately two months prior to admission, the patient was involved in a car accident followed
1A
iB Fic. l Case I. - Posteroanterior chest films. A. The epicardial pacemaker leads are intact. n. Two months later the broken pacemaker lead has migrated medially. 483
484
CLINICAL RADIOLOGY
Fro, 2 Case 1. - Chest films taken 17 months after the original pacemaker was broken. The posteroanterior (A) and lateral (B) projections show the broken lead has shifted position. On the right (c) and left (D) anterior oblique projections the lead cannot be separated from the cardiac silhouette. Thus a pericardial location is suggested.
MIGRATION
OF E P I C A R D I A L
PACEMAKER
LEADS
FIG. 3 Case 2. - Posteroanterior chest films. A. Post-operative film. R e d u n d a n c y o f course of the m o n o p o l a r epicardial lead is apparent. B. O n the following day, there is increased looping of the p a c e m a k e r lead. c a n d D. Six m o n t h s later the disconnected epicardial pacemaker lead is noted. T h e new transvenous electrode is in the right ventricular outflow tract.
485
486
CLINICAL RADIOLOGY
by chest pain, dyspnea, and dizziness. A chest X-ray taken at another hospital revealed a broken lead near its attachment to the pacemaker. The patient was being paced by the remaining intact wire. After admission to the Peter Bent Brigham Hospital, a chest film indicated that the broken pacemaker lead had migrated medially (Fig. IB). The patient's congestive heart failure improved after installation of a new pacemaker utilising the remaining intact wire. The broken wire was not removed. Seventeen months later the pacemaker was changed. Chest fihns at that time revealed a shift in position of the broken lead (Fig. 2). Case 2. - A 70-year-old white male with an 18-year history of angina entered with cardiac arrhythmia. Two years previously a transvenous pacemaker had been placed for heart block. Six months prior to admission, a monopolar epicardial pacemaker was placed due to difficulty in maintaining correct position of the transvenous pacemaker. The immediate post-operative chest film revealed looping of the pacemaker lead (Fig. 3A). On the following day the looped wire was noted to have migrated to a more superior position but was still functioning properly (Fig. 3n). The patient did well until the day of admission when he experienced a syncopal episode. He was found to have third-degree heart block, atrial flutter and pacemaker failure. Admission chest film revealed that the epicardial pacemaker wire was unchanged in position. The patient did well after placement of a new transvenous pacemaker. The malfunctioning epicardial pacemaker wire was left in place. Chest films show the disconnected epicardial lead (Fig. 3c, D). The transvenous electrode in the right ventricular outflow tract was subsequently repositioned. DISCUSSION The widespread use of epicardial placement of pacemaker leads is on the wane because o f the ease of the transvenous endocardiac m e t h o d (Tegtmeyer, 1972). However, there are still certain situations when the epicardial lead has a distinct advantage. In the pediatric age group the slack is needed for growth. W h e n the transvenous pacing electrode cannot adequately pace the heart, the placement o f epicardial leads becomes the method o f choice, even with the attendant dangers o f general anaesthesia. Other indications include the temporary need for a pacemaker after cardiac surgery or during atrial synchronous pacing. The complications o f epicardial electrodes which m a y eventually cause pacing failure have been well described (Haupt and Birkhead, 1965; Reinbert and Cooley, 1967): infection, oedema, or bleeding around any part o f the pacemaker apparatus, fracture of the leads, p o o r positioning, perforation, fibrosis at the implantation site, and generator or battery failure. Lead fracture is one
o f the most important complications. The lead wire is subjected to considerable stress especially where it enters the relatively fixed rib cage or at any angulation in its course (Haupt and Birkhead, 1965; Rosenbaum, 1965). The heart action and respiratory movements o f the thorax undoubtedly contribute to the stresses. A n y sort o f trauma, even t h o u g h t to be minor at the time, can cause lead wire breakage. In Case 1, lead fracture occurred after an automobile accident. Migration of the broken wire was probably caused by heart action with m o v e m e n t along a well formed sinus tract. The patient was worked up radiologically for the exact location of the migrated lead. Multiple oblique views showed that no part o f the lead projected beyond the cardiac shadow. This indicated the possibility that the wire was coiled within the pericardium rather than mediastinal in location. The patient managed to pace on the remaining intact lead which eventually failed. The eventual effect o f the broken lead remains to be determined. The radiopaque pacemaker lead is coated with biologically inert, radiolucent silicone rubber and probably has no local effect on tissue (Hall and Rosenbaum, 1971). In Case 2, migration of a m o n o p o l a r epicardial pacemaker occurred early in the post-operative course without lead breakage. This undoubtedly contributed to the eventual pacing failure. A possible cause o f the migration may have been undue slack in the subcutaneous course o f the pacemaker wire. The pacing failure itself was probably caused by dislodgement at the myocardial implantation site. REFERENCES HALL, W. M. & ROSEZ,~AUM,H. D. (1971). The radiology of cardiac pacemakers. Radiologie Clinics of North America, 9, 343-353. HAUPT, G. J. & BIRKHEAD, N. C. (1965). Implantable cardiac pacemakers. Advances in Biological and Medical Physics, 10, 357-393. REMBERT, F. M. & COOLEY, R. N. (1967). Implantable cardiac pacemakers: radiologic appearance. Texas Medicine, 63, 72-78. ROSEYnA~, H. D. (1965). Roentgen demonstration of broken cardiac pacemaker wires_ Radiology, 84, 933-936. TEGTMEV~a, C. J. (1972). The roentgenology of cardiac pacemakers. Contemporary Surgery, 1, 79-88. ZOLL, P. M. (1952). Resuscitation of the heart in ventricular standstill by external electric stimulation. New England Journal of Medicine, 274, 768-771.
MIGRATION MURRAY
OF EPICARDIAL
WATNICK, t IRAJ HOOSHMAND
PACEMAKER and HUGO
LEADS*
SPINDOLA-FRANCO
Department of Radiology, Harvard Medical School and Peter Bent Brigham Hospital, Boston, Massachusetts, U.S.A. T h e i m p l a n t a t i o n of p e r m a n e n t p a c e m a k e r s often gives rise to complications. M i g r a t i o n o f leads, an unusual complication, occurred in two of our p a t i e n t s with epicardial pacemakers. I n one case lead fracture and subsequent d i s p l a c e m e n t due to h e a r t a c t i o n occurred after an a u t o m o b i l e accident. In the second case l o o p i n g a n d migration o f the wire occurred within a day after i m p l a n t a t i o n a l t h o u g h the lead continued to f u n c t i o n p r o p e r l y for six months. The p r o b a b l e cause o f m i g r a t i o n in this p a t i e n t was excess slack. IT is now over 20 years since Zoll published his clinical p a p e r on external electric stimulation o f the h e a r t (Zoll, 1952). N u m e r o u s technical advances have occurred since then a n d m o r e are on the horizon. C o m p l i c a t i o n s s e c o n d a r y to insertion o f foreign materials into the b o d y are inevitable. It is therefore n o t surprising that there are m a n y
reports o f c o m p l i c a t i o n s following the surgical i m p l a n t a t i o n o f p e r m a n e n t pacemakers. This r e p o r t describes two p a c e m a k e r patients with a unique u n r e p o r t e d complication.
* This work was supported in part by USPHS grants HLl1668 and HL05832. t Present address: Noble Hospital, 115 West Silver Street, Westfield, Massachussets 01085.
Case 1. - A 56-year-old white male was admitted to the hospital with congestive heart failure and pacemaker dysfunction. Six years previously, the patient had an epicardial pacemaker placed for complete heart block with Stokes-Adams attacks. The battery was changed three years later. Chest film at that time showed intact pacemaker wires (Fig. la). Approximately two months prior to admission, the patient was involved in a car accident followed
1A
iB Fic. l Case I. - Posteroanterior chest films. A. The epicardial pacemaker leads are intact. n. Two months later the broken pacemaker lead has migrated medially. 483
484
CLINICAL RADIOLOGY
Fro, 2 Case 1. - Chest films taken 17 months after the original pacemaker was broken. The posteroanterior (A) and lateral (B) projections show the broken lead has shifted position. On the right (c) and left (D) anterior oblique projections the lead cannot be separated from the cardiac silhouette. Thus a pericardial location is suggested.
MIGRATION
OF E P I C A R D I A L
PACEMAKER
LEADS
FIG. 3 Case 2. - Posteroanterior chest films. A. Post-operative film. R e d u n d a n c y o f course of the m o n o p o l a r epicardial lead is apparent. B. O n the following day, there is increased looping of the p a c e m a k e r lead. c a n d D. Six m o n t h s later the disconnected epicardial pacemaker lead is noted. T h e new transvenous electrode is in the right ventricular outflow tract.
485
486
CLINICAL RADIOLOGY
by chest pain, dyspnea, and dizziness. A chest X-ray taken at another hospital revealed a broken lead near its attachment to the pacemaker. The patient was being paced by the remaining intact wire. After admission to the Peter Bent Brigham Hospital, a chest film indicated that the broken pacemaker lead had migrated medially (Fig. IB). The patient's congestive heart failure improved after installation of a new pacemaker utilising the remaining intact wire. The broken wire was not removed. Seventeen months later the pacemaker was changed. Chest fihns at that time revealed a shift in position of the broken lead (Fig. 2). Case 2. - A 70-year-old white male with an 18-year history of angina entered with cardiac arrhythmia. Two years previously a transvenous pacemaker had been placed for heart block. Six months prior to admission, a monopolar epicardial pacemaker was placed due to difficulty in maintaining correct position of the transvenous pacemaker. The immediate post-operative chest film revealed looping of the pacemaker lead (Fig. 3A). On the following day the looped wire was noted to have migrated to a more superior position but was still functioning properly (Fig. 3n). The patient did well until the day of admission when he experienced a syncopal episode. He was found to have third-degree heart block, atrial flutter and pacemaker failure. Admission chest film revealed that the epicardial pacemaker wire was unchanged in position. The patient did well after placement of a new transvenous pacemaker. The malfunctioning epicardial pacemaker wire was left in place. Chest films show the disconnected epicardial lead (Fig. 3c, D). The transvenous electrode in the right ventricular outflow tract was subsequently repositioned. DISCUSSION The widespread use of epicardial placement of pacemaker leads is on the wane because o f the ease of the transvenous endocardiac m e t h o d (Tegtmeyer, 1972). However, there are still certain situations when the epicardial lead has a distinct advantage. In the pediatric age group the slack is needed for growth. W h e n the transvenous pacing electrode cannot adequately pace the heart, the placement o f epicardial leads becomes the method o f choice, even with the attendant dangers o f general anaesthesia. Other indications include the temporary need for a pacemaker after cardiac surgery or during atrial synchronous pacing. The complications o f epicardial electrodes which m a y eventually cause pacing failure have been well described (Haupt and Birkhead, 1965; Reinbert and Cooley, 1967): infection, oedema, or bleeding around any part o f the pacemaker apparatus, fracture of the leads, p o o r positioning, perforation, fibrosis at the implantation site, and generator or battery failure. Lead fracture is one
o f the most important complications. The lead wire is subjected to considerable stress especially where it enters the relatively fixed rib cage or at any angulation in its course (Haupt and Birkhead, 1965; Rosenbaum, 1965). The heart action and respiratory movements o f the thorax undoubtedly contribute to the stresses. A n y sort o f trauma, even t h o u g h t to be minor at the time, can cause lead wire breakage. In Case 1, lead fracture occurred after an automobile accident. Migration of the broken wire was probably caused by heart action with m o v e m e n t along a well formed sinus tract. The patient was worked up radiologically for the exact location of the migrated lead. Multiple oblique views showed that no part o f the lead projected beyond the cardiac shadow. This indicated the possibility that the wire was coiled within the pericardium rather than mediastinal in location. The patient managed to pace on the remaining intact lead which eventually failed. The eventual effect o f the broken lead remains to be determined. The radiopaque pacemaker lead is coated with biologically inert, radiolucent silicone rubber and probably has no local effect on tissue (Hall and Rosenbaum, 1971). In Case 2, migration of a m o n o p o l a r epicardial pacemaker occurred early in the post-operative course without lead breakage. This undoubtedly contributed to the eventual pacing failure. A possible cause o f the migration may have been undue slack in the subcutaneous course o f the pacemaker wire. The pacing failure itself was probably caused by dislodgement at the myocardial implantation site. REFERENCES HALL, W. M. & ROSEZ,~AUM,H. D. (1971). The radiology of cardiac pacemakers. Radiologie Clinics of North America, 9, 343-353. HAUPT, G. J. & BIRKHEAD, N. C. (1965). Implantable cardiac pacemakers. Advances in Biological and Medical Physics, 10, 357-393. REMBERT, F. M. & COOLEY, R. N. (1967). Implantable cardiac pacemakers: radiologic appearance. Texas Medicine, 63, 72-78. ROSEYnA~, H. D. (1965). Roentgen demonstration of broken cardiac pacemaker wires_ Radiology, 84, 933-936. TEGTMEV~a, C. J. (1972). The roentgenology of cardiac pacemakers. Contemporary Surgery, 1, 79-88. ZOLL, P. M. (1952). Resuscitation of the heart in ventricular standstill by external electric stimulation. New England Journal of Medicine, 274, 768-771.