Late unexpected complete fracture of a right ventricular lead still capturing the myocardium

A 72-year-old man presented for routine dual chamber pacemaker interrogation 13 years following insertion for sick sinus syndrome. Increased noise, impedance and threshold of the right ventricular (RV) lead were identified. RV capture was maintained with an overall RV pacing burden of 47%. A routine generator replacement was scheduled alongside RV lead replacement. Fluoroscopy at the start of the procedure revealed an unexpected striking fracture of the RV pacing lead with complete separation of the proximal and distal portions within the RV. The patient was asymptomatic and described no predisposing factors. He underwent implantation of a new ventricular lead and generator and has remained well. This case demonstrates clear RV lead fracture as a late complication of pacemaker implantation despite maintained capture. This emphasises the need for a chest X-ray when a change in device parameters is noted at device interrogation even in the absence of symptoms.

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656 Cough, a rare and not well recognized symptom of lead perforation

European Heart Journal Supplements ◽

10.1093/eurheartj/suab127.026 ◽

2021 ◽

Vol 23 (Supplement_G) ◽

Author(s):

Francesca Parisi ◽

Elisabetta Demurtas ◽

Marta Allegra ◽

Lorenzo Pistelli ◽

Francesca Frecentese ◽

...

Keyword(s):

Pericardial Effusion ◽

Right Ventricular ◽

Rare Complication ◽

Pacemaker Implantation ◽

Productive Cough ◽

Loop Recorder ◽

Lead Perforation ◽

Ventricular Lead ◽

The Right ◽

Contrast Ct

Abstract Aims Along with relevant progress in technology, pacemaker implantation is continuously improving its safety and efficacy in treating patients with bradyarrhythmias. Despite this, this procedure has several complications, including haematoma, pneumothorax, lead dislodgement, infection, lead perforation, and tamponade. Methods and results A 64-year-old woman underwent loop recorder implantation, after recurrent loss of consciousness, in order to assess arrhythmic causes of syncope. Two weeks later, an episode of paroxysmal complete AV block, conditioning a pause of 3 s, was recorded. Thus, the patient was scheduled for urgent dual-chamber pacemaker implantation. No complication apparently occurred during the procedure. An active fixation ventricular lead was positioned in right ventricular septal apex while passive fixation atrium lead in the right appendage. Soon after implantation the patient started to suffer by non-productive cough, clearly related to ventricular stimulation, either in DDD or in VVI pacing modality. During spontaneous ventricular activation (RBBB) no symptoms occurred. Transthoracic echocardiography, performed the day after implantation, revealed a small pericardial effusion (diastolic diameter < 10 mm) along the apical segments, near the tip of the right ventricular lead. Suspicion of right ventricular lead perforation arised. The patient underwent urgent contrast chest CT confirming pericardial effusion, and showing an intramyocardium placement of the right ventricular apical lead. No active bleeding in pericardium was observed. Due to persistence of symptoms, we decided to perform right ventricular lead repositioning in right middle septum, with pericardiocentesis back-up promptly available. Post-procedure, palpitation, and cough abruptly disappeared. After 3 months follow-up, no significant symptoms were reported and pericardial effusion gradually disappeared. Conclusions We describe a singular case of cough, as atypical symptom immediately after pacemaker implantation. Pericardial effusion and contrast-CT showing intra-myocardial position of the tip guided our suspicion to a possible right ventricular lead microperforation. Although right ventricular lead parameters were completely normal this findings didn’t exclude RV perforation. The lead perforation is known as a rare complication of device implantation. Typical symptoms of RV lead perforation are chest pain and hypotension. The patient described in our case showed a haemodynamically stable pericardial effusion accompanied by non-productive cough, clearly time-related to RV stimulation. In literature, there is only another similar case report. The cough is a rare and not well recognized symptom of lead perforation. Early diagnosis of RV perforation allows to perform urgently and safely (pericardiocentesis back-up) lead replacement/repositioning. Echocardiography and contrast-CT could be useful in order to assess a possible pericardial effusion or intramyocardial/pericardial position of RV lead tip.

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Right ventricular perforation, pneumothorax, and a pneumatocele by a pacemaker lead: a case report

JA Clinical Reports ◽

10.1186/s40981-021-00470-8 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Shihoko Iwata ◽

Ayana Hirose ◽

Ikue Furui ◽

Takako Matsumoto ◽

Makoto Ozaki ◽

...

Keyword(s):

Right Ventricular ◽

Cystic Lesion ◽

Lung Resection ◽

Pacemaker Implantation ◽

Lead Extraction ◽

Pacemaker Lead ◽

Excellent Outcome ◽

Ventricular Lead ◽

Life Threatening ◽

The Right

Abstract Background Perforation of the right ventricle by a pacemaker lead is a rare and potentially life-threatening complication. We present a patient who developed right ventricular perforation, pneumothorax, and a cyst and underwent partial lung resection. Case presentation A 94-year-old woman was diagnosed with sick sinus syndrome and underwent a dual-chamber permanent pacemaker implantation. The next day, pacing failed and chest radiography showed that the right ventricular lead was outside the cardiac silhouette. Computed tomography revealed that the lead had perforated the right ventricular apex, causing a left-sided pneumothorax and a cystic lesion at the site of pulmonary injury by the pacemaker lead. The patient underwent lung resection and a right ventricular lead extraction. Pathological analysis revealed the cystic lesion to be an acute pneumatocele. Conclusions Pneumothorax and pneumatocele associated with right ventricular pacemaker lead perforation is extremely rare. In our case, a radical surgical intervention provided an excellent outcome.

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Surgical Repair of Subacute Right Ventricular Perforation after Pacemaker Implantation

Case Reports in Cardiology ◽

10.1155/2017/3242891 ◽

2017 ◽

Vol 2017 ◽

pp. 1-3 ◽

Cited By ~ 2

Author(s):

Takeshi Oda ◽

Takanori Kono ◽

Keiichi Akaiwa ◽

Yasushi Takahara ◽

Chie Yasuoka ◽

...

Keyword(s):

Right Ventricle ◽

Right Ventricular ◽

Rare Complication ◽

Pacemaker Implantation ◽

Median Sternotomy ◽

Axillary Vein ◽

Pericardial Cavity ◽

Temporary Pacing ◽

Pacing Lead ◽

The Right

We report an 84-year-old woman who presented with right ventricular perforation 4 days after pacemaker implantation for syncope due to sick sinus syndrome. Median sternotomy revealed no pericardial effusion, but the pacing lead had penetrated the right ventricle and pericardium. When the pleura was opened, the tip of the lead was seen in the visceral pleura. The lead was cut in the pericardial cavity and extracted from the left subclavian wound together with the generator. The right ventricular perforation was sutured and a temporary pacing lead was placed on the right ventricular wall intraoperatively. Ten days after the surgery, a new pacemaker lead was placed in the ventricular septum via the right axillary vein. Right ventricular perforation is a rare complication after pacemaker implantation. Typically, it occurs at the time of implantation or within 24 hours after implantation. In the present case, the perforation of the right ventricle which needed urgent surgery occurred 4 days after implanting the pacing lead at the right ventricular apex. Great care should have been taken not to overlook this life-threatening complication even more than 24 hours after pacemaker implantation.

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INFLUENCE OF RIGHT VENTRICULAR LEAD IMPLANTATION SITE CHOICE ON PACING EFFICIENCY

International Medical Journal ◽

10.37436/2308-5274-2019-4-3 ◽

2020 ◽

pp. 13-17

Author(s):

Dmitrii Aleksandrovich Lopyn ◽

Stanislav Valerevich Rybchynskyi ◽

Dmitrii Evgenevich Volkov

Keyword(s):

Heart Failure ◽

Right Ventricular ◽

Longitudinal Strain ◽

Treatment Options ◽

Global Longitudinal Strain ◽

Optimal Method ◽

Cardiac Stimulation ◽

Ventricular Lead ◽

The Right ◽

Stimulation Of

Currently the electrophysiological treatment options have been considered to be the most effective for many patients with arrhythmogenic cardiomyopathies, as well as in those with arrhythmias on the background of heart failure. Currently, the dependence of efficiency of the pacemakers on the location of the electrodes has been proven. In order to study the effect of a myocardial dysynchrony on the effectiveness of pacing depending on the location of the right ventricular electrode, an investigation has been performed. This study comprised the patients with a complete atrioventricular block, preserved ejection fraction of the left ventricle (more than 50 %), with no history of myocardial infarction, who were implanted with the two−chamber pacemaker. It has been established that the best results were achieved with a stimulation of the middle and lower septal zone of the right ventricle, the worst ones were obtained with a stimulation of its apex. It has been found that the dynamics of the magnitude of segmental strains and a global longitudinal strain coincided with the dynamics of other parameters of the pacemaker effectiveness, which indicated the pathogenetic value of myocardial dysynchrony in the progression of heart failure after implantation of the pacemaker. Therefore it could be concluded that the studying of myocardial mobility by determining a longitudinal strain for assessing the functional state of the myocardium and the effectiveness of pacing is highly advisable. It is emphasized that the use of the latest strains−dependent techniques for cardiac performance evaluation in the patients with bradyarrhythmia have a great potential to predict the development of chronic heart failure and to choose the optimal method of physiological stimulation of the heart. Key words: right ventricular lead, cardiac stimulation, myocardial dyssynchrony.

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Usefulness of lead delivery catheter system for true right ventricular septal pacing

European Heart Journal ◽

10.1093/ehjci/ehaa946.0770 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

K Miyajima ◽

T Urushida ◽

K Ito ◽

F Kin ◽

A Okazaki ◽

...

Keyword(s):

Right Ventricular ◽

Pacemaker Implantation ◽

Septal Wall ◽

Catheter Group ◽

Catheter System ◽

Septal Pacing ◽

Ventricular Activation ◽

Pacing Lead ◽

Guiding Catheter ◽

Delivery Catheter

Abstract Background Right ventricular (RV) septal pacing is often selected to preserve a more physiologic ventricular activation. But the pacing leads are not always located in true septal wall, rather in hinge or free wall in some cases with the conventional stylet-guided lead implantation. In recent years, new guiding catheter systems has attracted attention as a solution to that problem. Objective The aim of this study is to investigate that true ventricular sepal pacing can be achieved by use of the new guiding catheter system for pacing lead. Methods We enrolled 198 patients who underwent RV septal lead implantation and computed tomography (CT) after pacemaker implantation. 16 cases were used delivery catheter (Delivery), and 182 cases were used stylet for targeting ventricular septum (Conventional). We analyzed the lead locations with CT, and evaluated capture thresholds, R-wave amplitudes, lead impedances and 12-lead electrocardiogram findings one month after implantation. Results All cases of delivery catheter group had true septal lead positions (Delivery; 100% vs Conventional; 44%, p<0.01). Capture thresholds and lead impedances had not significant differences between between two groups (0.65±0.15V vs 0.60±0.15V, p=0.21, 570±95Ω vs 595±107Ω, p=0.39, respectively). R-wave amplitudes were significantly higher in delivery catheter group (13.0±4.8mV vs 10±4.6mV, p<0.01). Paced QRS durations were shorter in delivery catheter group (128±16ms vs 150±21ms, p<0.01). Conclusions The delivery catheter system designated for pacing lead can contribute to select the true ventricular septal sites and to attain the more physiologic ventricular activation. Funding Acknowledgement Type of funding source: None

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Detrimental immediate and long-term clinical effects of right ventricular pacing in patients with myocardial fibrosis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.304 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

C Saunderson ◽

MF Paton ◽

LAE Brown ◽

J Gierula ◽

PG Chew ◽

...

Keyword(s):

Heart Failure ◽

Right Ventricular ◽

Pacemaker Implantation ◽

Mechanical Dyssynchrony ◽

Volume Index ◽

Lv Function ◽

P Value ◽

Rv Pacing ◽

Dyssynchrony Index

Abstract Funding Acknowledgements Type of funding sources: None. Background Long-term right ventricular (RV) pacing leads to heart failure or a decline in left ventricular (LV) function in up to a fifth of patients. Objectives We aimed to establish whether patients with focal fibrosis detected on late gadolinium enhancement cardiovascular magnetic resonance (CMR) have deterioration in LV function after RV pacing. Methods We recruited 110 patients (84 in final analysis) into two observational CMR studies. Patients (n = 34) with a dual chamber device and preserved atrioventricular (AV) conduction underwent CMR in two asynchronous pacing modes (AOO & DOO) to compare intrinsic conduction with RV pacing. Patients (n = 50) with high-grade AV block underwent CMR before and 6 months after pacemaker implantation to investigate the long-term effects of RV pacing. Results: The three key findings were 1) Initiation of RV pacing in patients with fibrosis, compared to those without, was associated with greater immediate changes in both LV end-systolic volume index (LVESVi) (5.3 ± 3.5 vs 2.1 ± 2.4 mL/m2; p < 0.01) and LV ejection fraction (LVEF) (-5.7 ± 3.4% vs -3.2 ± 2.6%; p = 0.02); 2) Long-term RV pacing in patients with fibrosis, compared to those without, was associated with greater changes in LVESVi (8.0 ± 10.4 vs -0.6 ± 7.3 mL/m2; p = 0.008) and LVEF (-12.3 ± 7.9 vs -6.7 ± 6.2%; p = 0.012); 3) Patients with fibrosis did not experience an improvement in quality of life, biomarkers or functional class after pacemaker implantation. Conclusions Fibrosis detected on CMR is associated with immediate and long-term deterioration in LV function following RV pacing and could be used to identify those at risk of heart failure prior to pacemaker implantation. Characteristics before and after pacing Study 1 No fibrosis (n = 16) Fibrosis (n = 18) AOO DOO p-value AOO DOO p-value LVEDVi - mL/m² 66 ± 13 66 ± 12 0.67 78 ± 14 79 ± 13 0.34 LVESVi - mL/m² 30 ± 10 32 ± 9 0.003 38 ± 11 43 ± 12 <0.001 LVEF - % 56 ± 6 53 ± 5 <0.001 52 ± 8 47 ± 9 <0.001 Mechanical Dyssynchrony index - ms 61 ± 17 71 ± 25 0.07 81 ± 18 89 ± 21 0.04 Study 2 No fibrosis (n = 19) Fibrosis (n = 31) Pre-PPM Post-PPM p-value Pre-PPM Post-PPM p-value LVEDVi -mL/m² 88 ± 21 73 ± 14 <0.001 90 ± 18 83 ± 21 0.007 LVESVi -mL/m² 35 ± 9 34 ± 9 0.71 41 ± 14 49 ± 21 0.001 LVEF - % 60 ± 5 54 ± 7 <0.001 56 ± 8 43 ± 12 <0.001 Mechanical Dyssynchrony index - ms 70 ± 29 81 ± 22 0.15 84 ± 30 98 ± 31 0.03 Abstract Figure. Mechanism for heart failure after pacing

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Video-Assisted Implantation of a Left Ventricular Lead and Intrathoracic Tunneling to a Right-Sided CRT-D Device

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e3182372464 ◽

2011 ◽

Vol 6 (5) ◽

pp. 341-343

Author(s):

Thijs Stoker ◽

Theo J. Klinkenberg ◽

Alexander H. Maass ◽

Massimo A. Mariani

Keyword(s):

Left Ventricular ◽

Pleural Space ◽

Left Ventricular Lead ◽

Cardiac Resynchronization ◽

Ventricular Pacing ◽

Video Assisted ◽

Ventricular Lead ◽

Pacing Lead ◽

Left Ventricular Pacing ◽

The Right

We describe two cases in which a biventricular implantable cardioverter defibrillator for cardiac resynchronization therapy had to be placed on the right side due to unsuitability of the left subclavian vein. Endocardial implantation of a left ventricular lead through the coronary sinus was previously attempted but was unsuccessful. Implantation of the epicardial left ventricular pacing lead was performed through video-assisted thoracic surgery on the left side. The connector end of the left ventricular pacing lead was tunnelized through the anterior mediastinum into the right pleural space. The right-sided pocket was then opened. A tunnel was created from the pocket to the thoracic wall, and the pleural space was entered over the second rib. The lead was retrieved from the right pleural space and connected with the Cardiac resynchronization therapy-device (CRT-D). Both procedures and postoperative periods were uneventful. Intrathoracic left-to-right tunneling of an epicardial left ventricular lead by video-assisted thoracic surgery is feasible and safe. It provides an alternative to subcutaneous tunneling.

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P3527Echocardiographic assessment of the right ventricle in chronic heart failure with focus on patients with atrial fibrillation

European Heart Journal ◽

10.1093/eurheartj/ehz745.0391 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

E Majos ◽

A Kraska ◽

I Kowalik ◽

E Smolis-Bak ◽

H Szwed ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Right Ventricle ◽

Right Ventricular ◽

Systolic Function ◽

Pressure Overload ◽

Ventricular Ejection Fraction ◽

Rv Pacing ◽

The Right ◽

Rv Function

Abstract Background Assessment of the right ventricle (RV) in heart failure (HF) is challenging and requires applicable methods and parameters. Atrial fibrillation (AF) is a common and clinically significant arrhythmia in 30–50% of HF patients. Assessment of the RV function in patients with AF is problematic. Still little is known about RV function in HF and AF patients. The aim of the study was to assess RV function in HF with focus on AF patients. Methods Patients with HF of ischemic etiology, NYHA II-III, LVEF ≤40%, with AF and sinus rhythm (SR), underwent two- and three- dimensional echocardiography (2DE and 3DE) for assessment of the RV with use of multiple parameters. The RV was examined for: linear dimensions, end-diastolic and end-systolic areas adjusted to body surface area (RV EDA and RV ESA/BSA) and end-diastolic and end-systolic volumes adjusted to lean body mass (RV EDV and RV ESV/LBM) to reflect volume overload and in terms of right ventricular pressure (RVSP) as an index of pressure overload. RV systolic function was assessed with 2DE: tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RV FAC), tricuspid lateral annular systolic velocity (s') and 3DE parameters: right ventricular ejection fraction (RVEF) and free wall right ventricular longitudinal strain (FW RVLS). Also, TAPSE/RVSP parameter was included. Results The study included 126 patients: 94 with AF and 32 with SR. Within the AF group 28 patients were treated medically, 41 had RV pacing (pacemaker or an implantable cardioverter-defibrillator, ICD) and 25 had cardiac resynchronisation therapy (CRT). In comparison with SR group AF patients had: larger RV inflow tract dimension (4.49±0.85 vs. 3.95±0.72 cm; p=0.0017), RV EDA/BSA (12.7±3.9 vs. 11.1±3.0 cm2/m2; p=0.0358) and RV ESA/BSA (8.0±3.0 vs. 6.7±2.4 cm2/m2; p=0.0226). Similarly, patients with AF had greater RV volumes in 3DE than patients with SR: RV EDV/LBM (1.82±0.60 vs. 1.61±0.38ml/kg, p=0.0267) and RV ESV/LBM (1.11±0.40 ml/kg vs. 0.81±0.28, p<0,0001). Also, in patients with AF right ventricular systolic pressure (RVSP) was higher (40.8±10.2 vs. 34.0±8.1 mmHg, p=0,0010). No differences in TAPSE and RVFAC were found but the relation TAPSE/RVSP was higher in AF than in SR group (0.51±0.21 vs. 0.65±0.24 cm/mmHg; p=0.0046). Also, in AF patients in comparison to SR group some parameters had worse values: s' (9.7±2.31 vs. 12.1±3.83, p=0.014), RVEF (37.2±7.3 vs. 48.2±7.5, p<0.0001 and FW RVLS (−18.3±4.6 vs. −23.9±4.23%, p<0,0001). Within the AF group no significant differences in studied variables depending on RV pacing or CRT were found. Conclusions Larger volumes and higher pressure overload of the RV were observed in patients with AF in comparison to SR. Systolic function of the RV seems to be more depressed in AF compared to SR patients with systolic heart failure. Further research in larger groups is required to identify the most applicable and valuable methods of RV evaluation.

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Incidental Detection of Persistent Left Superior Vena Cava during Transvenous Pacing

Journal of Perioperative Echocardiography ◽

10.5005/jp-journals-10034-1038 ◽

2015 ◽

Vol 3 (2) ◽

pp. 52-54

Author(s):

S Subash ◽

Divya Gopal ◽

Ashwini Thimmarayappa

Keyword(s):

Superior Vena Cava ◽

Superior Vena ◽

Central Venous Access ◽

Pacemaker Implantation ◽

Vena Cava ◽

Venous Access ◽

Left Superior Vena Cava ◽

Persistent Left Superior Vena ◽

Pacing Lead ◽

Chest X Ray

ABSTRACT Patients with persistent left superior vena cava (PLSVC) are usually asymptomatic, but due to its anatomical defects, difficulties in establishing central venous access, pacemaker implantation and cardiothoracic surgery are common. We report a case of 65 years old patient who presented with complete heart block in cardiac critical care and, after emergency transvenous pacing, the chest X-ray showed unusual course of the transvenous pacing lead, which on further transthoracic echocardiographic (TTE) evaluation demonstrated dilated coronary sinus with PLSVC. How to cite this article Subash S, Gopal D, Thimmarayappa A. Incidental Detection of Persistent Left Superior Vena Cava during Transvenous Pacing. J Perioper Echocardiogr 2015; 3(2):52-54.

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