Surgical epicardial left ventricular lead implantation as a troubleshooting step for a left ventricular lead fracture following difficult transvenous implants in cardiac resynchronisation therapy patients: a case report

Troubleshooting of left ventricular (LV) lead fractures in cardiac resynchronisation therapy patients is important, especially for those with limited and problematic transvenous LV lead placement. In this case, surgical epicardial LV lead implantation was employed.

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.

Positional syncope occurring just at the right time in a patient with a permanent pacemaker: a case report

We present an unusual case of positional syncope occurring years after pacemaker implantation due to pacemaker lead fracture resulting from subclavian-crush syndrome. The syncope occurred incidentally during hospital admission and was timely diagnosed using an integrated approach of history taking, examination findings, device interrogation and radiographic parameters. The patient subsequently underwent lead and device revision which led to resolution of her symptoms. Continuous...

Dorsal root ganglion stimulation lead fractures: potential mechanisms and ways to avoid

Dorsal root ganglion stimulation (DRGS) therapy is a rapidly emerging tool being used by pain physicians in the treatment of chronic pain. Complex regional pain syndrome (CRPS), a debilitating disease whose mechanism is still has yet to be fully elucidated, is a common pathology targeted by DRGS therapy, often better results than traditional spinal cord stimulation. DRGS therapy, however, is not bereft of complications. Lead migration and fracture are two examples in particular that are among the most common of these complications. The authors report an unusual case of lost efficacy due to lead fractures in patients with CRPS treated with DRGS. The case report narrates identification, management and probable mechanism of DRGS lead fracture. The structural instability of DRGS leads can yield distressing symptoms at any point during the therapy, and physicians should be cognisant of the complications of DRGS therapy.

Gradually increasing impedance in patients with pacemakers and implantable defibrillators: a watchful waiting strategy

Funding Acknowledgements Type of funding sources: None. Introduction Pacing impedance measurements are important in the surveillance of pacemaker and implantable cardioverter/defibrillator (ICD) devices. Whereas sudden changes in impedances can reflect lead fracture or isolation defects, gradually increasing impedances are thought to occur because of calcifications at the endomyocardial interface. In many cases, these leads are replaced prophylactically but this has not been studied systematically. Purpose We aimed to identify the outcome of right ventricular (RV) electrodes with high impedances that were left active in this single center study. Methods All patients in the electronic patient database were screened for impedances >1200Ohms. 41,201 individual recordings led to 207 individual patients. 161 patients were excluded from the analysis due to sudden impedance increase, temporarily high impedances or wrong entry. Of the remaining 46 patients, baseline characteristics as well as pacing impedance, sensing values, pacing thresholds, and shock impedance in case of ICDs were recorded. Results There were 17 pacemaker and 29 ICD patients, 68 ± 15 years old, 70% were male. Glomerular filtration rate at baseline was 81 ± 22 ml/min/1.73m2. Baseline RV impedance was 597 ± 123Ohms. During follow-up impedances increased to 1875 ± 682Ohms (p < 0,001). Pacing thresholds increased from 0,6 ± 0,4V to 3,0 ± 1,9V (p < 0,001). Sensing remained stable. The median time from implant to impedance rise >1000Ohms was 5,5 (3,4-7)years and median follow-up thereafter 2,4 years (1,2-4,2). During follow-up, no intervention was performed for 33 leads (72%). No events occurred. 13 leads (28%) were replaced , 9 prophylactically (mostly because of ICD advisory leads), 3 because of high pacing thresholds and high percentage pacing and one lead because of noise oversensing, probably unrelated as it occurred 7 years after impedance increase. Conclusions A watchful waiting strategy appears to be a safe option for patients with ICDs and pacemakers with low percentage pacing. As impedance increase cannot be used for surveillance for imminent lead fracture, other means such as short interval counts and non-sustained oversensing have to be employed and should be combined with remote monitoring.

Twiddler’s syndrome after implantation of baroreflex activation therapy: a case report

Background Twiddler’s syndrome is a rare complication after implantation of cardiac pacemakers or cardioverter-defibrillators that usually occurs within the first year after the procedure. However, it has not yet been described following implantation of baroreflex activation therapy (BAT). Case summary A 61-year-old female patient was referred to the cardiology outpatient clinic due to uncontrolled arterial hypertension despite maximal doses of several established drugs. Therefore, right-sided BAT implantation was successfully performed in February 2017 with good clinical response. Because of sustained neck pain at the site of stimulator, surgical revision was performed in November 2019 including a switch of the lead to the contralateral position. Approximately 1 month later, Twiddler’s syndrome was identified on the basis of recurrent pain at the generator site necessitating pocket-revision, however, the lead was only untwisted but not replaced. A few weeks afterwards, unfortunately, lead revision was indispensable due to lead fracture. Discussion This case presents the uncommon phenomenon of Twiddler’s syndrome after BAT implantation. In addition, the commonly twisted lead should always be replaced as well during surgical pocket-revision in order to ensure proper long-term function.