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The Migrating Electrode
CASE REPORTS
The Migrating Electrode Complication of Transvenous Electrical Pacing of the Heart Renato G. Terzi, M.D., and Peter Hutchin, M.D.
S
ince the introduction of permanent transvenous electrical pacing of the heart [ S ] , great improvements have been made in the performance of the pulse generator and its electronic components. Transvenous pacing has been used with increasing frequency, but opinions still differ as to the best venous route for insertion of the endocardial electrode. The external jugular vein probably has been employed most widely [3, 7, 101. Leininger and Neville [6] have recommended the use of the internal jugular vein. When this route is used, the catheter electrode is less likely to be affected by the motion of the neck and shoulder girdles, and dislodgement of the electrode from the right ventricle may be prevented. Recently, we have encountered two patients in whom displacement of the endocardial electrode followed the use of the right internal jugular vein. CASE REPORTS CASE
1
C. M. L. (NCMH 21-82-15), a 69-year-old white female, was admitted to North Carolina Memorial Hospital with a history of several episodes of dizziness without syncope in the preceding year. She was found to have complete heart block, with a pulse rate between 40 and 50 per minute. Because of a poor response to drug therapy, it was elected to implant a fixed-rate permanent pacemaker." Under fluoroscopic control, the endocardial electrode was positioned in the right ventricle via the right internal jugular vein. A postoperative chest x-ray demonstrated satisfactory position of the electrode in the apex of the right From the Division of Thoracic and Cardiovascular Surgery, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, N.C. Accepted for publication August 9, 1968. 'Medtronic, Inc., Minneapolis, Minn.
458
THE ANNALS OF THORACIC SURGERY
CASE REPORT:
Migrating Pacemaker Electrodes
B
A
FIG. 1. Chest x-ray in Case 1 demonstrating the position of the endocardial electrode immediately after its insertion i n t o the right ventricle via the right internal jugular v e i n ( A ) and jive weeks later (B), after displacement of the catheter electrode had occurred.
ventricle (Fig. 1A). One month following her discharge from the hospital, while leaning back in a dentist’s chair, the patient noted a sudden onset of abdominal pulsations. She was readmitted to the hospital with complete heart block. Both rectus muscles were noted to contract rhythmically at the rate setting of the pulse generator. Chest x-rays showed that the catheter tip had migrated from the right ventricle into the inferior vena cava at the level of the right diaphragm (Fig. 1B). At operation the catheter electrode was exposed under local anesthesia in the right supraclavicular fossa and repositioned in the right ventricle. The following day a pericardial friction rub was heard, and impending perforation of the right ventricle was suspected and confirmed fluoroscopically. The right supraclavicular incision was reopened and the endocardial electrode withdrawn and repositioned in the apex of the right ventricle. The patient made a good recovery and was discharged from the hospital a week later. After a six-week interval, the patient was readmitted with complete heart block and visible abdominal pulsations at the rate setting of the pulse generator. Chest x-rays revealed that the catheter tip had been displaced again from the right ventricle and was lying low in the right atrium. The right supraclavicular area was opened for the third time. The suture used to hold the endocardial electrode in position was found to have broken, permitting sliding motion of the catheter electrode within the jugular vein. The electrode was once more repositioned in the right ventricle and firmly secured to the surrounding tissue. The patient has done well since then, over a four-month follow-up period. CASE
2
P. S. (NCMH 21-35-68),a 67-year-old Negro female, was admitted to North Carolina Memorial Hospital with a history of syncopal episodes occurring approximately once a month for a period of 3 years. She was found to have a sinus bradycardia with a rate of 54 per minute. A transvenous demand pacemaker* was implanted, using the right internal jugular vein for the catheter electrode (Fig. 2A). *Medtronic Inc., Minneapolis, Minnesota.
VOL.
6,
NO.
5,
NOV.,
1968
459
TERZI AND HUTCHIN
A
B
FIG. 2. Chest x-ray in Case 2 demonstrating the position of the endocardial electrode in the apex of the right ventricle initially ( A ) and five months later (B), after it had been displaced into the right atrium. Note that the proximal end of the catheter electrode became wound around the generator. I t was not possible t o reposition the catheter electrode, which was firmly adherent t o the right atrial wall. The postoperative course was uncomplicated. After her discharge from the hospital, the patient failed to return for postoperative follow-up visits. When she was seen five months after insertion of the pacemaker, her chest x-ray revealed that the catheter tip had migrated from the right ventricle into the right atrium, and the proximal end of the catheter was noted to be wound around the generator (Fig. 2B). An electrocardiogram showed a first-degree heart block and a pacemaker artifact, but no paced QRS complex was present. The cardiac rhythm was regular at a rate of 60 per minute. The patient denied manipulation of the battery unit or the catheter electrode. She was readmitted to the hospital, and the supraclavicular incision was reopened under local anesthesia. An attempt was made to reposition the catheter electrode; however, the tip of the electrode was firmly adherent to the wall of the right atrium and could not be moved. It was therefore left in the right atrium, and the pulse generator was removed. Postoperatively, the patient maintained a satisfactory heart rate and has remained well on follow-up visits.
DISCUSSION
Of all complications related to the use of permanent transvenous electrical pacing of the heart, dislodgement of the endocardial electrode is probably the single most common cause of premature pacemaker failure [l 11. Although use of the internal jugular vein for implantation of permanent transvenous pacemakers does have several technical advantages over the use of the external jugular vein [6], displacement of the catheter electrode from the right ventricle may still occur, as shown in the foregoing case reports. 460
THE ANNALS OF THORACIC SURGERY
CASE REPORT:
Migrating Pacemaker Electrodes
With the use of either the external or the internal jugular venous system, the catheter electrode may be acutely angulated in the neck, producing a traction force that withdraws the catheter from the right ventricle unless it is firmly wedged in its muscular trabeculations. Hyperextension of the neck and elevation of the arms above the head favor the occurrence of such a displacement, despite fixation of the catheter electrode to the soft tissues of the neck [S]. T h e patient’s manipulation of the battery unit may similarly displace the catheter tip from the right ventricle [ 123. Dislodgement of the catheter electrode is usually an early complication of permanent transvenous pacing. It occurs before the catheter electrode has become firmly adherent to the right ventricular endocardium and other points of contact in the right atrium and superior vena cava [l]. Such fixation is desirable, as it will prevent catheter electrode displacement. If the catheter electrode becomes adherent to the endothelium after dislodgement has occurred, as in the second case report, simple repositioning of the catheter electrode will not be possible. The fibrous reaction about the electrode is usually detectable in a few days, but may not be complete until after several weeks or months [7]. It is important, therefore, to instruct the patient to avoid extreme movements of the neck and shoulders as well as marked elevation of the arms during this time to prevent catheter electrode displacement. T h e axillary venous route for permanent transvenous electrical pacing of the heart [2, 91 may be an alternative approach in the prevention of catheter electrode displacement. Since the axillary vein is an infraclavicular structure, the catheter electrode is protected in this position during motion of the neck and also, to some extent, during movement of the shoulder girdles. No electrode displacements have been seen in a small series of patients in whom the left cephalic vein was employed [4].Further experience with the axillary venous route is needed to establish its true usefulness in this regard. SUMMARY
Two patients are reported with permanent transvenous pacemakers complicated by displacement of the endocardial electrode from the right ventricle. In both patients the right internal jugular vein was employed for insertion of the endocardial catheter electrode. Measures that may decrease the incidence of this complication are discussed. REFERENCES 1. Furman, S., and Escher, D. J. W. Retained endocardial pacemaker electrodes. J . Thorac. Cardiovasc. Surg. 55:737, 1968. VOL.
6,
NO.
5,
NOV.,
1968
461
TERZI AND HUTCHIN
2. Furman, S., Escher, D. J. W., Solomon, N., and Schwedel, J. B. Implanted
transvenous pacemakers. Ann. Surg. 164:465, 1966. 3. Harthorne, J. W., Austen, W. G., Corning, H., McNamara, J. J., and Sanders, C. A. Permanent endocardial pacing in complete heart block. Ann. Intern. M e d . 66:831, 1967. 4. King, S. M., Arrington, J. O., and Dalton, M. L. Permanent transvenous cardiac pacing via the left cephalic vein. Ann. Thorac. Surg. 5:469, 1968. 5. Lagergren, H., and Johansson, L. Intracardiac stimulation for complete heart block. Acta Chir. Scand. 125:562, 1963. 6. Leininger, B. J., and Neville, W. E. Use of the internal jugular vein for implantations of permanent transvenous pacemakers. Ann. Thorac. Surg. 5:61, 1968. 7. Morris, J. J., Whalen, R. E., McIntosh, H. D., Thompson, H. K., Brown, I. W., Jr., and Young, W. G., Jr. Permanent ventricular pacemakers. Circulation 36:587, 1967. 8. Morse, D. P., Nichols, H. T., Blanco, G., Adam, A., and Monheit, R. Comparative study of pacemakers. Dis. Chest 51:74, 1967. 9. Parsonnet, V., Zucker, I. R., Gilbert, L., Brief, D. K., and Alpert, J. Implantable transvenous pacemakers: A two and one-half year evaluation. Dis. Chest 53:247, 1968. 10. Smyth, N. P. D. Technique for insertion of transvenous endocardial pacemaker. J. Thorac. Cardiovasc. Surg. 51:755, 1966. 11. Sowton, E. Cardiac pacemakers and pacing. - M o d . Conc. Cardiovasc. Dis. 36:31, 1967. 12. Stanford, W., Coyle, F. L., Dooley, B. N., and Hood, R. H., Jr. Transvenous pacemaker failure: Migration of catheter lead by patient manipulation. Ann. Thorac. Surg. 5:162, 1968.
462
THE ANNALS OF THORACIC SURGERY
The Migrating Electrode Complication of Transvenous Electrical Pacing of the Heart Renato G. Terzi, M.D., and Peter Hutchin, M.D.
S
ince the introduction of permanent transvenous electrical pacing of the heart [ S ] , great improvements have been made in the performance of the pulse generator and its electronic components. Transvenous pacing has been used with increasing frequency, but opinions still differ as to the best venous route for insertion of the endocardial electrode. The external jugular vein probably has been employed most widely [3, 7, 101. Leininger and Neville [6] have recommended the use of the internal jugular vein. When this route is used, the catheter electrode is less likely to be affected by the motion of the neck and shoulder girdles, and dislodgement of the electrode from the right ventricle may be prevented. Recently, we have encountered two patients in whom displacement of the endocardial electrode followed the use of the right internal jugular vein. CASE REPORTS CASE
1
C. M. L. (NCMH 21-82-15), a 69-year-old white female, was admitted to North Carolina Memorial Hospital with a history of several episodes of dizziness without syncope in the preceding year. She was found to have complete heart block, with a pulse rate between 40 and 50 per minute. Because of a poor response to drug therapy, it was elected to implant a fixed-rate permanent pacemaker." Under fluoroscopic control, the endocardial electrode was positioned in the right ventricle via the right internal jugular vein. A postoperative chest x-ray demonstrated satisfactory position of the electrode in the apex of the right From the Division of Thoracic and Cardiovascular Surgery, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, N.C. Accepted for publication August 9, 1968. 'Medtronic, Inc., Minneapolis, Minn.
458
THE ANNALS OF THORACIC SURGERY
CASE REPORT:
Migrating Pacemaker Electrodes
B
A
FIG. 1. Chest x-ray in Case 1 demonstrating the position of the endocardial electrode immediately after its insertion i n t o the right ventricle via the right internal jugular v e i n ( A ) and jive weeks later (B), after displacement of the catheter electrode had occurred.
ventricle (Fig. 1A). One month following her discharge from the hospital, while leaning back in a dentist’s chair, the patient noted a sudden onset of abdominal pulsations. She was readmitted to the hospital with complete heart block. Both rectus muscles were noted to contract rhythmically at the rate setting of the pulse generator. Chest x-rays showed that the catheter tip had migrated from the right ventricle into the inferior vena cava at the level of the right diaphragm (Fig. 1B). At operation the catheter electrode was exposed under local anesthesia in the right supraclavicular fossa and repositioned in the right ventricle. The following day a pericardial friction rub was heard, and impending perforation of the right ventricle was suspected and confirmed fluoroscopically. The right supraclavicular incision was reopened and the endocardial electrode withdrawn and repositioned in the apex of the right ventricle. The patient made a good recovery and was discharged from the hospital a week later. After a six-week interval, the patient was readmitted with complete heart block and visible abdominal pulsations at the rate setting of the pulse generator. Chest x-rays revealed that the catheter tip had been displaced again from the right ventricle and was lying low in the right atrium. The right supraclavicular area was opened for the third time. The suture used to hold the endocardial electrode in position was found to have broken, permitting sliding motion of the catheter electrode within the jugular vein. The electrode was once more repositioned in the right ventricle and firmly secured to the surrounding tissue. The patient has done well since then, over a four-month follow-up period. CASE
2
P. S. (NCMH 21-35-68),a 67-year-old Negro female, was admitted to North Carolina Memorial Hospital with a history of syncopal episodes occurring approximately once a month for a period of 3 years. She was found to have a sinus bradycardia with a rate of 54 per minute. A transvenous demand pacemaker* was implanted, using the right internal jugular vein for the catheter electrode (Fig. 2A). *Medtronic Inc., Minneapolis, Minnesota.
VOL.
6,
NO.
5,
NOV.,
1968
459
TERZI AND HUTCHIN
A
B
FIG. 2. Chest x-ray in Case 2 demonstrating the position of the endocardial electrode in the apex of the right ventricle initially ( A ) and five months later (B), after it had been displaced into the right atrium. Note that the proximal end of the catheter electrode became wound around the generator. I t was not possible t o reposition the catheter electrode, which was firmly adherent t o the right atrial wall. The postoperative course was uncomplicated. After her discharge from the hospital, the patient failed to return for postoperative follow-up visits. When she was seen five months after insertion of the pacemaker, her chest x-ray revealed that the catheter tip had migrated from the right ventricle into the right atrium, and the proximal end of the catheter was noted to be wound around the generator (Fig. 2B). An electrocardiogram showed a first-degree heart block and a pacemaker artifact, but no paced QRS complex was present. The cardiac rhythm was regular at a rate of 60 per minute. The patient denied manipulation of the battery unit or the catheter electrode. She was readmitted to the hospital, and the supraclavicular incision was reopened under local anesthesia. An attempt was made to reposition the catheter electrode; however, the tip of the electrode was firmly adherent to the wall of the right atrium and could not be moved. It was therefore left in the right atrium, and the pulse generator was removed. Postoperatively, the patient maintained a satisfactory heart rate and has remained well on follow-up visits.
DISCUSSION
Of all complications related to the use of permanent transvenous electrical pacing of the heart, dislodgement of the endocardial electrode is probably the single most common cause of premature pacemaker failure [l 11. Although use of the internal jugular vein for implantation of permanent transvenous pacemakers does have several technical advantages over the use of the external jugular vein [6], displacement of the catheter electrode from the right ventricle may still occur, as shown in the foregoing case reports. 460
THE ANNALS OF THORACIC SURGERY
CASE REPORT:
Migrating Pacemaker Electrodes
With the use of either the external or the internal jugular venous system, the catheter electrode may be acutely angulated in the neck, producing a traction force that withdraws the catheter from the right ventricle unless it is firmly wedged in its muscular trabeculations. Hyperextension of the neck and elevation of the arms above the head favor the occurrence of such a displacement, despite fixation of the catheter electrode to the soft tissues of the neck [S]. T h e patient’s manipulation of the battery unit may similarly displace the catheter tip from the right ventricle [ 123. Dislodgement of the catheter electrode is usually an early complication of permanent transvenous pacing. It occurs before the catheter electrode has become firmly adherent to the right ventricular endocardium and other points of contact in the right atrium and superior vena cava [l]. Such fixation is desirable, as it will prevent catheter electrode displacement. If the catheter electrode becomes adherent to the endothelium after dislodgement has occurred, as in the second case report, simple repositioning of the catheter electrode will not be possible. The fibrous reaction about the electrode is usually detectable in a few days, but may not be complete until after several weeks or months [7]. It is important, therefore, to instruct the patient to avoid extreme movements of the neck and shoulders as well as marked elevation of the arms during this time to prevent catheter electrode displacement. T h e axillary venous route for permanent transvenous electrical pacing of the heart [2, 91 may be an alternative approach in the prevention of catheter electrode displacement. Since the axillary vein is an infraclavicular structure, the catheter electrode is protected in this position during motion of the neck and also, to some extent, during movement of the shoulder girdles. No electrode displacements have been seen in a small series of patients in whom the left cephalic vein was employed [4].Further experience with the axillary venous route is needed to establish its true usefulness in this regard. SUMMARY
Two patients are reported with permanent transvenous pacemakers complicated by displacement of the endocardial electrode from the right ventricle. In both patients the right internal jugular vein was employed for insertion of the endocardial catheter electrode. Measures that may decrease the incidence of this complication are discussed. REFERENCES 1. Furman, S., and Escher, D. J. W. Retained endocardial pacemaker electrodes. J . Thorac. Cardiovasc. Surg. 55:737, 1968. VOL.
6,
NO.
5,
NOV.,
1968
461
TERZI AND HUTCHIN
2. Furman, S., Escher, D. J. W., Solomon, N., and Schwedel, J. B. Implanted
transvenous pacemakers. Ann. Surg. 164:465, 1966. 3. Harthorne, J. W., Austen, W. G., Corning, H., McNamara, J. J., and Sanders, C. A. Permanent endocardial pacing in complete heart block. Ann. Intern. M e d . 66:831, 1967. 4. King, S. M., Arrington, J. O., and Dalton, M. L. Permanent transvenous cardiac pacing via the left cephalic vein. Ann. Thorac. Surg. 5:469, 1968. 5. Lagergren, H., and Johansson, L. Intracardiac stimulation for complete heart block. Acta Chir. Scand. 125:562, 1963. 6. Leininger, B. J., and Neville, W. E. Use of the internal jugular vein for implantations of permanent transvenous pacemakers. Ann. Thorac. Surg. 5:61, 1968. 7. Morris, J. J., Whalen, R. E., McIntosh, H. D., Thompson, H. K., Brown, I. W., Jr., and Young, W. G., Jr. Permanent ventricular pacemakers. Circulation 36:587, 1967. 8. Morse, D. P., Nichols, H. T., Blanco, G., Adam, A., and Monheit, R. Comparative study of pacemakers. Dis. Chest 51:74, 1967. 9. Parsonnet, V., Zucker, I. R., Gilbert, L., Brief, D. K., and Alpert, J. Implantable transvenous pacemakers: A two and one-half year evaluation. Dis. Chest 53:247, 1968. 10. Smyth, N. P. D. Technique for insertion of transvenous endocardial pacemaker. J. Thorac. Cardiovasc. Surg. 51:755, 1966. 11. Sowton, E. Cardiac pacemakers and pacing. - M o d . Conc. Cardiovasc. Dis. 36:31, 1967. 12. Stanford, W., Coyle, F. L., Dooley, B. N., and Hood, R. H., Jr. Transvenous pacemaker failure: Migration of catheter lead by patient manipulation. Ann. Thorac. Surg. 5:162, 1968.
462
THE ANNALS OF THORACIC SURGERY