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Pericardial tamponade due to perforation with a permanent endocardial pacing catheter
Pericardial tamponade due to perforation with a permanent endocardial pacing catheter A case is presented in which shock developed suddenly during implantation of a permanent pacemaker. The cause proved to be pericardia I tamponade secondary to catheter perforation. Analysis of this case and the 6 similar cases reported in the literature reveals that although perforation occurs not infrequently from immediately to many months after implantation, tamponade is quite rare and is invariably closely related temporally to catheter manipulation. Tamponade has occurred with different catheter sizes and makes. It is more likely related to local myocardial factors than to faulty technique. Closed pericardiocentesis is generally unsuccessful in relieving the tamponade, and prompt open drainage through the subxiphoid approach is recommended. Mayer M. Bassan, M.D., and Gideon Merin, M.D., Jerusalem, Israel
Since its introduction more than a decade ago, permanent endocardial pacing has become the preferred method for the management of advanced atrioventricular block as well as other disturbances of cardiac rhythm. We wish to describe a rare, life-threatening complication of this treatment modality which, if recognized in time, can generally be remedied with no residual deleterious effects.
Case report A 67-year-old woman was admitted for the sernielective implantation of a permanent ventricular pacemaker. She had the sick sinus syndrome, bradycardia-tachycardia type, with numerous documented episodes of paroxysmal atrial fibrillation as well as sinus bradycardia of 40 to 45 beats per minute. Two previous episodes of transient cerebral ischemia were thought to have been related to the cardiac arrhythmia. On examination, the blood pressure was 140/100 mm. Hg and the pulse rate 50 beats per minute and regular. Venous pressure was clinically normal, and the lungs were clear. A slight left ventricular heave was noted, and a fourth sound was heard. An electrocardiogram revealed sinus bradycardia and borderline left ventricular hypertrophy, without evidence of prior infarction. The chest x-ray film was considered normal. On the third hospital day, a No. 5 Fr. USCI temporary bipolar pacing catheter was positioned in the right ventricle via the right femoral vein. The cardiac rhythm was noted to From The Departments of Internal Medicine D and Cardiovascular Surgery, Hadassah Medical Center, Jerusalem, Israel. Received for publication Nov. 23, 1976. Accepted for publication Jan. 13, 1977. Address for reprints: Mayer M. Bassan, M.D., Department of Internal Medicine, Hadassah Hospital, Mt. Scopus, Jerusalem, Israel.
have converted to atrial fibrillation with a ventricular rate of 75 to 85 beats per minute. The following morning, the patient was taken to the operating room in a fasted state following the intramuscular injection of meperidine, 40 mg., and diazepam, 10 mg. After a local anesthetic was given, the right cephalic vein was isolated and a Medtronic No. 6904 permanent bipolar endocardial electrode (No. 10 Fr., tip diameter 3.2 mm.) was passed into the right ventricle. After several minutes of manipulation with the two stiffening stylets in place, the catheter tip was positioned in the apex of the heart at the left cardiac border. Threshold for the proximal electrode in the unipolar mode was approximately I ma.; however because the threshold was above 10 mao for the distal electrode, the catheter was partially withdrawn and another position sought. Approximately 10 minutes later, the patient's ventricular rate had slowed from 75 to 50 beats per minute, and the systolic blood pressure had dropped from 130 to 50 mm. Hg. The patient was cold and lethargic. Possible causes for this sudden deterioration were considered to be vasovagal reaction, dehydration plus the effects of premedication, myocardial infarction, and ventricular perforation with tamponade. In view of the rarity of the latter and the inability to manage the shock effectively if it were due to a myocardial infarction, we gave the patient 1.0 mg. of atropine intravenously and speeded up the infusion of 5 per cent glucose. Meanwhile, the pacing catheter was repositioned to obtain a satisfactory threshold, and a No. 5950 (rate 70) Medtronic pacemaker was connected and implanted under the right breast. Despite the rise in pulse rate to 80 beats per minute as a result of the atropine, at the end of the procedure the patient remained in a state of shock with the blood pressure palpated at 60 mm. Hg. At this time, some observers felt that pulsus paradoxus was present on palpation of the carotid artery. A central venous catheter was inserted, and the central venous pressure was found to be 17 ern. H 20 , with a normal fall on inspiration. A chest x-ray film showed no change in the cardiac silhouette. The heart was in a ventricular paced
51
52
The Journal of Thoracic and Cardiovascular Surgery
Bassan and Merin
Table I. Summary of reported cases of tamponade owing to pacing catheters lmplanttamponade interval
Permanent or temporary
Tip diameter (mm.)
20
T T
2.0 2.3
7 days Hours
Blind repositioning Blind manipulation
Not done Not done
None None
22
P
4.0
0
During implantation
Thoracotomy
22
P
4.0
0
During implantation
17
P
3.2
7 days
17
P
3.8
17 mo.
17
P
3.8
23
P
Present case
P
2.2-3.0 flange 3.2
Several months 0
6 hr. after withdrawal and repositioning on Day 7 During withdrawal and repositioning of perforating catheter During repositioning of perforating catheter During implantation
75 C.c. blood, BP rose; 28 mm. paradox remained 200 c.c, blood, BP rose; paradox persisted 25 C.c. bloody fluid; patient improved Not attempted
0
During implantation
Ref No. 19
Circumstances of tamponade
Operation
Results of pericardiocentesis
Thoracotomy None
Not attempted
Small parasternal incision; thoracotomy Thoracotomy
Unsuccessful
Thoracotomy
20 c.c, blood; no improvement Subxiphoid open pericardiocentesis; no thoracotomy
Legend: BP, Blood pressure. RV, Right ventricle.
rhythm, with good QRS amplitude. An echocardiogram was suggestive of pericardial fluid, but was not definitive. Two attempts at pericardiocentesis with a No. 17 Fr., 6 inch Angiocath via the subxiphoid approach yielded 20 C.c. of blood which clotted after 10 minutes. At this point, when the patient had been in shock for approximately 2Vz hours, she was returned to the operating room. The pericardium was exposed with the use of local anesthesia by means of a subxiphoid incision through the linea alba. Opening the pericardium released a gush of dark blood. The opening was extended, and approximately 300 c.c. of blood was recovered. The systolic blood pressure rose immediately to 120 mm. Hg. The pericardial sac was irrigated with normal saline, and no further bleeding was observed. A pericardial drain was positioned, and the incision closed. The postoperative course was uneventful, and the patient was discharged with a well-functioning pacemaker and no apparent aftereffects from the episode of tamponade.
Discussion Myocardial perforation by pacing catheters has been described extensively in the literature.v" In the case of temporary catheters, the incidence in different series":" has ranged from 2 per cent! to 20 per cent," a variance reflecting differences in duration of pacing but, more importantly, differences in the extent of efforts to detect perforation and in the opportunities for diagnosis. The higher incidences were from the series in which the ventricle was examined at thoracotomy during implantation of epicardial electrodes. Despite the greater flexibility of permanent endocardial electrode catheters, perforation of the myocardium has also been a not infrequent complication of their
use. 9 - 18 This has been true with many different sizes and makes. Although in some series of permanent implantations the claim is made that this problem is encountered rarely or not at all,": 8 most authors'r"? have been impressed with a significant incidence, ranging from 3 9 to 9 per cent. 10 The majority of these perforations have occurred within days or weeks of implantation and have been discovered because of sudden pacing failure. 9, 10. 12, 13 Late perforation has also been described months to years after implantation, frequently on routine chest film or because of diaphragmatic contractions, often without pacing failure. 6. 18 The management of both early and late perforation by pacing catheters, either temporary or permanent, has in the great majority of instances consisted of their withdrawal and repositioning within the ventricle. It is of special interest, therefore, that only 8 cases of pericardial tamponade owing to perforating pacing catheters have been reported. 17, 19,20,22,23 The features of these cases are summarized in Table I. Two of these!" 20 occurred with temporary catheters. Both patients died, and the diagnoses were made at autopsy. Additional instances": 21 have been described in which, at thoracotomy for epicardial electrode placement, 50 to 300 C.c. of blood was found along with a perforating temporary catheter, although there had been no preceeding signs of circulatory embarrassment or tamponade. In only one reported case" was significant bleeding described as the catheter was withdrawn under direct vision.
Volume 74 Number 1 JUly, 1977
Pericardial tamponade
Findings at operation Condition
Further bleeding
Outcome
Autopsy: pericardium filled with blood Autopsy: 700 c.c. blood; tip in pericardium Tense pericardium; 100 C.c. blood
No
Recovery
200c.c, blood
No
Recovery
Death Death
Recovery
200 C.c. blood; perforation seen
?
Recovery
Tamponade
?
Recovery
300c.c. blood; two holes in RV
No
Recovery
300c.c, blood
No
Recovery
Only 6 cases of tamponade resulting from a perforating permanent catheter have been previously reported .17, 22, 23 Despite the many reports of spontaneous perforation, all the occurrences of tamponade have been associated with catheter manipulation. Three of the episodes occurred during the initial positioning and the other three at the time of withdrawal and repositioning of a perforating catheter. Shock developed suddenly during manipulation in 5 of the cases and 6 hours later in one. Perforation of the myocardium is clearly related to the impacting maneuvers peculiar to the manipulation of pacing catheters. No instances of perforation were described in a multi-center, cooperative report on the complications encountered in almost 4,000 diagnostic right heart catheterizations in patients older than 40 years of age. 2 In view of the many perforations which occur in the early postimplantation period, it seems likely that many perforations must also occur during the implantation procedure, most of which are undetected. The reasons for this include the difficulty in recognizing an extramyocardial position on an anteroposterior fluoroscopic view; the fact that failure to capture at an individual position is not a cause for careful investigation during implantation, as opposed to postoperatively; and the extreme rarity of clinical consequences as a result of perforation and withdrawal. The importance of faulty technique as a factor in myocardial perforation is unclear. Since it is routine
53
practice to ascertain stability of position by advancing the catheter until it buckles, it would appear that the maximum possible pressure would be applied to the ventricular wall in every case. Nevertheless, the fewer such maneuvers per implantation, the less the likelihood of perforation. Imparato and Kim 1 7 have related the occurrence of tamponade to perforation with large diameter (>3.2 mm.) catheters, which, although less likely to perforate, are more likely to cause tamponade when they do. Although there may be some validity to this point, 5 of the 9 reported cases of tamponade involved catheters 3.2 mm. in diameter or less (Table I). In addition, there are many reports of perforations with catheters 4 mm. and even 6 mm. in diameter which have not led to
tamponade.wP-
18
Perforation appears to be most related to the strength of the right ventricular myocardium at the site of impaction. Similarly, bleeding must also be a result of unusual local conditions, such as necrotic or fibrotic myocardium, since the right ventricle is a relatively low-pressure chamber which almost always seals itself. Thus tamponade is a very rare consequence of perforation, although lesser degrees of bleeding may cause little or no circulatory embarrassment and therefore go undetected. 5 Pericardiocentesis, despite repeated attempts, was unsuccessful in relieving the tamponade in our patient, as it was in 3 of the 4 other cases in which it was performed. This failure may well be related to the relatively small amount of blood in the pericardial sac during acute tamponade, as well as to the presence of clots. In contrast to the other cases in which pericardiocentesis was unsuccessful or not attempted, our patient was not subjected to thoracotomy. Rather, we exposed and drained the pericardium through the subxiphoid approach, a simpler and less traumatic procedure. Following the pericardial drainage, no further bleeding was noted. This was the case in at least two of the other five pericardiotomies and quite probably in the other three as well. Apparently, a limited exposure will be adequate and formal thoracotomy or even extension of the subxiphoid incision is unlikely to be necessary in most instances. The 2V2 hour delay in instituting definitive therapy to relieve the tamponade in our patient was a result of our reluctance to recognize the possibility of such a development. Our hesitancy stemmed from our previous experience in several hundred implantations. In addition, we were reluctant to subject such an ill patient to a possibly dangerous and unnecessary thoracotomy. Based on the present case, as well as other cases
54 Bassan and Merin
reported in the literature, in the event of sudden circulatory collapse during endocardial electrode implantation, we would recommend prompt open pericardiocentesis through a subxiphoid approach with local anesthesia. If available, emergency echocardiography beforehand may be useful in confirming the diagnosis. Whether there should be an initial attempt at closed pericardiocentesis is questionable. A negative result would not rule out tamponade, and the small likelihood of definitive therapeutic benefit may well be outweighed by the risk involved. REFERENCES
2
3
4
5
6
7
8
9
Lumia, F. J., and Rios, J. C.: Temporary Transvenous Pacemaker Therapy: An Analysis of Complications, Chest 64: 604, 1973. Braunwald, E., and Swan, H. 1. C.; Cooperative Study on Cardiac Catheterization, Circulation 38: 8; 36; 1968 (Supp!. III). Van Durme, 1. P., Heyndrickx, G., Snoeck, J., et a!.: Diagnosis of Myocardial Perforation by Intracardiac Electrograms Recorded From the Indwelling Catheter, J. Electrocardio!.6: 97, 1973. Edmundowitz, A. C., Morgan, D. Z., and Marshall, R. J.: Perforation of the Right Ventricle: A Complication of Endocardial Catheter Pacemaking, Circulation 32: 1180, 1965. Nathan, D. A., Center, S., Pina, R. E., etal.: Perforation During Indwelling Catheter Pacing, Circulation 33: 128, 1966. Meyer, 1. A., and Millar, K.: Perforation of the Right Ventricle by Electrode Catheters: A Review and Report of 9 Cases, Ann Surg 168: 1048, 1968. Grogler, F. M., Frank, G., Greven, G., Dragojevic, D., Oelert, H., Leitz, K., Dalichau, H., Brinke, U., Lohlein, D., Rogge, D., Hetzer, R., Hennersdorf, G., and Borst, H. G.: Complications of Permanent Transvenous Cardiac Pacing, J. THORAC. CARDIOVASC. SURG. 69: 895, 1975. Torresani, J., Jausseran, 1. M., Bernard, J., et al.: Advantages of Permanent Endocardial Pacing: Surgical Technique and Results, J. Cardiovasc. Surg. 14: 535, 1973. Hurwitz, B. J., Zion, M. M., and Promund Obel, I. W.: Myocardial Perforation by Flexible Elema Endocardial Pacing Catheters, Thorax 29: 678, 1974.
The Journal of Thoracic and Cardiovascular Surgery
10 Bernstein, V., Rotem, C. E., and Peretz, D. I.: Permanent Pacemakers: 8 Year Follow-up Study. Incidence and Management of Congestive Cardiac Failure and Perforations, Ann. Int. Med. 74: 361, 1971. II Morris, 1. 1., Whalen, R. E., and Mcintosh, H. D.: Permanent Ventricular Pacemakers: Comparison of Transthoracic and Transvenous Approaches, Circulation 36: 587, 1967. 12 Furman, S., Escher, D. J. W., and Solomon, N.: Experiences With Myocardial and Transvenous Implanted Cardiac Pacemakers, Am. J. Cardio!' 23: 66, 1969. 13 Hawthorne, J. W., Leinbach, R. c., Sanders, C. A., et a!.: Clinical Results of Transvenous Pacing, Ann. N. Y. Acad. Sci. 167: 1008, 1969. 14 McLaughlin,1. S., Cohen, M. L., Singleton, R., Attar, S., Scherlis, L., and Cowley, R. A.: Permanent Transvenous Catheter Pacing: Six Year Experience, J. THORAC. CARDIOVASC. SURG. 66: 771, 1973. 15 Barold, S. S., and Center, S.: Electrocardiographic Diagnosis of Perforation of the Heart by Pacing Catheter Electrode, Am. 1. Cardio!. 24: 274, 1969. 16 Kaplinsky, E.: Experience in Permanent Pacemaker Implantation in Israel, Ann. Cardio!. Angeio!. 20: 305, 1971. 17 Imparato, A. M., and Kim, G. E.: Electrode Complications in Patients With Permanent Cardiac Pacemakers, Arch. Surg. 105: 705, 1972 (also personal communication). 18 Rubenfire, M., Anbe, D. T., Drake, E. H., et a!.: Clinical Evaluation of Myocardial Perforation as a Complication of Permanent Transvenous Pacemakers, Chest 63: 185, 1973. 19 Furman, S., Schwedel, J. B., Robinson, G., and Hurwitt, E. S.: Use of an Intracardiac Pacemaker in the Control of Heart Block, Surgery 49: 98, 1961. 20 Hirose, T., Vera, C. A., Bailey, C. P., et a!.: Perforation of the Right Ventricular Wall by the Endocardial Pacing Catheter, Dis. Chest 54: 510, 1968. 21 Jorgensen, E. 0., Lyngborg, K., and Wennevold, A.: Unusual Sign of Perforation of a Pacemaker Catheter, Am. Heart J. 74: 732, 1967. 22 Mullen, D. c.. Porter, J. M., Thompson, H. K., et a!.: Cardiac Tamponade From Ventricular Perforation by a Transvenous Pacemaker, J. A. M. A. 203: 164, 1968. 23 Kalloor, G. 1.: Cardiac Tamponade: Report of a Case After Insertion of Transvenous Electrode, Am. Heart J. 88: 88, 1974.
Since its introduction more than a decade ago, permanent endocardial pacing has become the preferred method for the management of advanced atrioventricular block as well as other disturbances of cardiac rhythm. We wish to describe a rare, life-threatening complication of this treatment modality which, if recognized in time, can generally be remedied with no residual deleterious effects.
Case report A 67-year-old woman was admitted for the sernielective implantation of a permanent ventricular pacemaker. She had the sick sinus syndrome, bradycardia-tachycardia type, with numerous documented episodes of paroxysmal atrial fibrillation as well as sinus bradycardia of 40 to 45 beats per minute. Two previous episodes of transient cerebral ischemia were thought to have been related to the cardiac arrhythmia. On examination, the blood pressure was 140/100 mm. Hg and the pulse rate 50 beats per minute and regular. Venous pressure was clinically normal, and the lungs were clear. A slight left ventricular heave was noted, and a fourth sound was heard. An electrocardiogram revealed sinus bradycardia and borderline left ventricular hypertrophy, without evidence of prior infarction. The chest x-ray film was considered normal. On the third hospital day, a No. 5 Fr. USCI temporary bipolar pacing catheter was positioned in the right ventricle via the right femoral vein. The cardiac rhythm was noted to From The Departments of Internal Medicine D and Cardiovascular Surgery, Hadassah Medical Center, Jerusalem, Israel. Received for publication Nov. 23, 1976. Accepted for publication Jan. 13, 1977. Address for reprints: Mayer M. Bassan, M.D., Department of Internal Medicine, Hadassah Hospital, Mt. Scopus, Jerusalem, Israel.
have converted to atrial fibrillation with a ventricular rate of 75 to 85 beats per minute. The following morning, the patient was taken to the operating room in a fasted state following the intramuscular injection of meperidine, 40 mg., and diazepam, 10 mg. After a local anesthetic was given, the right cephalic vein was isolated and a Medtronic No. 6904 permanent bipolar endocardial electrode (No. 10 Fr., tip diameter 3.2 mm.) was passed into the right ventricle. After several minutes of manipulation with the two stiffening stylets in place, the catheter tip was positioned in the apex of the heart at the left cardiac border. Threshold for the proximal electrode in the unipolar mode was approximately I ma.; however because the threshold was above 10 mao for the distal electrode, the catheter was partially withdrawn and another position sought. Approximately 10 minutes later, the patient's ventricular rate had slowed from 75 to 50 beats per minute, and the systolic blood pressure had dropped from 130 to 50 mm. Hg. The patient was cold and lethargic. Possible causes for this sudden deterioration were considered to be vasovagal reaction, dehydration plus the effects of premedication, myocardial infarction, and ventricular perforation with tamponade. In view of the rarity of the latter and the inability to manage the shock effectively if it were due to a myocardial infarction, we gave the patient 1.0 mg. of atropine intravenously and speeded up the infusion of 5 per cent glucose. Meanwhile, the pacing catheter was repositioned to obtain a satisfactory threshold, and a No. 5950 (rate 70) Medtronic pacemaker was connected and implanted under the right breast. Despite the rise in pulse rate to 80 beats per minute as a result of the atropine, at the end of the procedure the patient remained in a state of shock with the blood pressure palpated at 60 mm. Hg. At this time, some observers felt that pulsus paradoxus was present on palpation of the carotid artery. A central venous catheter was inserted, and the central venous pressure was found to be 17 ern. H 20 , with a normal fall on inspiration. A chest x-ray film showed no change in the cardiac silhouette. The heart was in a ventricular paced
51
52
The Journal of Thoracic and Cardiovascular Surgery
Bassan and Merin
Table I. Summary of reported cases of tamponade owing to pacing catheters lmplanttamponade interval
Permanent or temporary
Tip diameter (mm.)
20
T T
2.0 2.3
7 days Hours
Blind repositioning Blind manipulation
Not done Not done
None None
22
P
4.0
0
During implantation
Thoracotomy
22
P
4.0
0
During implantation
17
P
3.2
7 days
17
P
3.8
17 mo.
17
P
3.8
23
P
Present case
P
2.2-3.0 flange 3.2
Several months 0
6 hr. after withdrawal and repositioning on Day 7 During withdrawal and repositioning of perforating catheter During repositioning of perforating catheter During implantation
75 C.c. blood, BP rose; 28 mm. paradox remained 200 c.c, blood, BP rose; paradox persisted 25 C.c. bloody fluid; patient improved Not attempted
0
During implantation
Ref No. 19
Circumstances of tamponade
Operation
Results of pericardiocentesis
Thoracotomy None
Not attempted
Small parasternal incision; thoracotomy Thoracotomy
Unsuccessful
Thoracotomy
20 c.c, blood; no improvement Subxiphoid open pericardiocentesis; no thoracotomy
Legend: BP, Blood pressure. RV, Right ventricle.
rhythm, with good QRS amplitude. An echocardiogram was suggestive of pericardial fluid, but was not definitive. Two attempts at pericardiocentesis with a No. 17 Fr., 6 inch Angiocath via the subxiphoid approach yielded 20 C.c. of blood which clotted after 10 minutes. At this point, when the patient had been in shock for approximately 2Vz hours, she was returned to the operating room. The pericardium was exposed with the use of local anesthesia by means of a subxiphoid incision through the linea alba. Opening the pericardium released a gush of dark blood. The opening was extended, and approximately 300 c.c. of blood was recovered. The systolic blood pressure rose immediately to 120 mm. Hg. The pericardial sac was irrigated with normal saline, and no further bleeding was observed. A pericardial drain was positioned, and the incision closed. The postoperative course was uneventful, and the patient was discharged with a well-functioning pacemaker and no apparent aftereffects from the episode of tamponade.
Discussion Myocardial perforation by pacing catheters has been described extensively in the literature.v" In the case of temporary catheters, the incidence in different series":" has ranged from 2 per cent! to 20 per cent," a variance reflecting differences in duration of pacing but, more importantly, differences in the extent of efforts to detect perforation and in the opportunities for diagnosis. The higher incidences were from the series in which the ventricle was examined at thoracotomy during implantation of epicardial electrodes. Despite the greater flexibility of permanent endocardial electrode catheters, perforation of the myocardium has also been a not infrequent complication of their
use. 9 - 18 This has been true with many different sizes and makes. Although in some series of permanent implantations the claim is made that this problem is encountered rarely or not at all,": 8 most authors'r"? have been impressed with a significant incidence, ranging from 3 9 to 9 per cent. 10 The majority of these perforations have occurred within days or weeks of implantation and have been discovered because of sudden pacing failure. 9, 10. 12, 13 Late perforation has also been described months to years after implantation, frequently on routine chest film or because of diaphragmatic contractions, often without pacing failure. 6. 18 The management of both early and late perforation by pacing catheters, either temporary or permanent, has in the great majority of instances consisted of their withdrawal and repositioning within the ventricle. It is of special interest, therefore, that only 8 cases of pericardial tamponade owing to perforating pacing catheters have been reported. 17, 19,20,22,23 The features of these cases are summarized in Table I. Two of these!" 20 occurred with temporary catheters. Both patients died, and the diagnoses were made at autopsy. Additional instances": 21 have been described in which, at thoracotomy for epicardial electrode placement, 50 to 300 C.c. of blood was found along with a perforating temporary catheter, although there had been no preceeding signs of circulatory embarrassment or tamponade. In only one reported case" was significant bleeding described as the catheter was withdrawn under direct vision.
Volume 74 Number 1 JUly, 1977
Pericardial tamponade
Findings at operation Condition
Further bleeding
Outcome
Autopsy: pericardium filled with blood Autopsy: 700 c.c. blood; tip in pericardium Tense pericardium; 100 C.c. blood
No
Recovery
200c.c, blood
No
Recovery
Death Death
Recovery
200 C.c. blood; perforation seen
?
Recovery
Tamponade
?
Recovery
300c.c. blood; two holes in RV
No
Recovery
300c.c, blood
No
Recovery
Only 6 cases of tamponade resulting from a perforating permanent catheter have been previously reported .17, 22, 23 Despite the many reports of spontaneous perforation, all the occurrences of tamponade have been associated with catheter manipulation. Three of the episodes occurred during the initial positioning and the other three at the time of withdrawal and repositioning of a perforating catheter. Shock developed suddenly during manipulation in 5 of the cases and 6 hours later in one. Perforation of the myocardium is clearly related to the impacting maneuvers peculiar to the manipulation of pacing catheters. No instances of perforation were described in a multi-center, cooperative report on the complications encountered in almost 4,000 diagnostic right heart catheterizations in patients older than 40 years of age. 2 In view of the many perforations which occur in the early postimplantation period, it seems likely that many perforations must also occur during the implantation procedure, most of which are undetected. The reasons for this include the difficulty in recognizing an extramyocardial position on an anteroposterior fluoroscopic view; the fact that failure to capture at an individual position is not a cause for careful investigation during implantation, as opposed to postoperatively; and the extreme rarity of clinical consequences as a result of perforation and withdrawal. The importance of faulty technique as a factor in myocardial perforation is unclear. Since it is routine
53
practice to ascertain stability of position by advancing the catheter until it buckles, it would appear that the maximum possible pressure would be applied to the ventricular wall in every case. Nevertheless, the fewer such maneuvers per implantation, the less the likelihood of perforation. Imparato and Kim 1 7 have related the occurrence of tamponade to perforation with large diameter (>3.2 mm.) catheters, which, although less likely to perforate, are more likely to cause tamponade when they do. Although there may be some validity to this point, 5 of the 9 reported cases of tamponade involved catheters 3.2 mm. in diameter or less (Table I). In addition, there are many reports of perforations with catheters 4 mm. and even 6 mm. in diameter which have not led to
tamponade.wP-
18
Perforation appears to be most related to the strength of the right ventricular myocardium at the site of impaction. Similarly, bleeding must also be a result of unusual local conditions, such as necrotic or fibrotic myocardium, since the right ventricle is a relatively low-pressure chamber which almost always seals itself. Thus tamponade is a very rare consequence of perforation, although lesser degrees of bleeding may cause little or no circulatory embarrassment and therefore go undetected. 5 Pericardiocentesis, despite repeated attempts, was unsuccessful in relieving the tamponade in our patient, as it was in 3 of the 4 other cases in which it was performed. This failure may well be related to the relatively small amount of blood in the pericardial sac during acute tamponade, as well as to the presence of clots. In contrast to the other cases in which pericardiocentesis was unsuccessful or not attempted, our patient was not subjected to thoracotomy. Rather, we exposed and drained the pericardium through the subxiphoid approach, a simpler and less traumatic procedure. Following the pericardial drainage, no further bleeding was noted. This was the case in at least two of the other five pericardiotomies and quite probably in the other three as well. Apparently, a limited exposure will be adequate and formal thoracotomy or even extension of the subxiphoid incision is unlikely to be necessary in most instances. The 2V2 hour delay in instituting definitive therapy to relieve the tamponade in our patient was a result of our reluctance to recognize the possibility of such a development. Our hesitancy stemmed from our previous experience in several hundred implantations. In addition, we were reluctant to subject such an ill patient to a possibly dangerous and unnecessary thoracotomy. Based on the present case, as well as other cases
54 Bassan and Merin
reported in the literature, in the event of sudden circulatory collapse during endocardial electrode implantation, we would recommend prompt open pericardiocentesis through a subxiphoid approach with local anesthesia. If available, emergency echocardiography beforehand may be useful in confirming the diagnosis. Whether there should be an initial attempt at closed pericardiocentesis is questionable. A negative result would not rule out tamponade, and the small likelihood of definitive therapeutic benefit may well be outweighed by the risk involved. REFERENCES
2
3
4
5
6
7
8
9
Lumia, F. J., and Rios, J. C.: Temporary Transvenous Pacemaker Therapy: An Analysis of Complications, Chest 64: 604, 1973. Braunwald, E., and Swan, H. 1. C.; Cooperative Study on Cardiac Catheterization, Circulation 38: 8; 36; 1968 (Supp!. III). Van Durme, 1. P., Heyndrickx, G., Snoeck, J., et a!.: Diagnosis of Myocardial Perforation by Intracardiac Electrograms Recorded From the Indwelling Catheter, J. Electrocardio!.6: 97, 1973. Edmundowitz, A. C., Morgan, D. Z., and Marshall, R. J.: Perforation of the Right Ventricle: A Complication of Endocardial Catheter Pacemaking, Circulation 32: 1180, 1965. Nathan, D. A., Center, S., Pina, R. E., etal.: Perforation During Indwelling Catheter Pacing, Circulation 33: 128, 1966. Meyer, 1. A., and Millar, K.: Perforation of the Right Ventricle by Electrode Catheters: A Review and Report of 9 Cases, Ann Surg 168: 1048, 1968. Grogler, F. M., Frank, G., Greven, G., Dragojevic, D., Oelert, H., Leitz, K., Dalichau, H., Brinke, U., Lohlein, D., Rogge, D., Hetzer, R., Hennersdorf, G., and Borst, H. G.: Complications of Permanent Transvenous Cardiac Pacing, J. THORAC. CARDIOVASC. SURG. 69: 895, 1975. Torresani, J., Jausseran, 1. M., Bernard, J., et al.: Advantages of Permanent Endocardial Pacing: Surgical Technique and Results, J. Cardiovasc. Surg. 14: 535, 1973. Hurwitz, B. J., Zion, M. M., and Promund Obel, I. W.: Myocardial Perforation by Flexible Elema Endocardial Pacing Catheters, Thorax 29: 678, 1974.
The Journal of Thoracic and Cardiovascular Surgery
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