Pacemaker complications

This chapter acknowledges that although pacemaker implantation is a relatively simple technique, there are significant complications that can occur at different times. Peri-procedural complications, such as failed venous access, air embolus, and cardiac perforation are described, including early warning signs and management methods. Intermediate complications such as haematoma and dislodgement of the lead tip are covered. Late complications, including thrombosis, ‘Twiddler’s syndrome’, and the appearance of manufacturing defects are also described, along with management techniques.

Chest Radiographs Are Valuable in Demonstrating Clinically Significant Pacemaker Complications that Require Reoperation

Purpose To evaluate the utility of chest radiography in demonstrating clinically significant pacemaker complications that required reoperation. Methods In this retrospective case-controlled series, we identified 14 consecutive adults who required pacemaker reoperation and who had chest radiographs available for review (6 men, 8 women; mean age, 71 years [range, 43–95 years]). Ten patients had pacemakers implanted at our institution, and 4 were referred for reoperation. Forty-two controls, 3 for each patient, had postoperative chest radiographs and normal device function (25 men, 17 women; mean age 76 years [range, 37–96 years]). All postoperative chest radiographs, including 1-year follow-ups, were blindly reviewed by at least 2 of 4 radiologists for lead perforation and position of right atrial and right ventricular leads. Follow-up radiographs were assessed for lead perforation, lead displacement, and lead fracture. Data were analysed by using the Fisher exact test. Results Of the patients, 1.7% (10/581) required reoperation for pacemaker dysfunction (noncapture, oversensing, abnormal atrial and ventricular thresholds, failing impedance), extracardiac stimulation, and lead perforation and/or displacement. There were no lead fractures. Chest radiographs demonstrated pacemaker complications in 57% of patients (8/14) at a median of 2 days (<1–32 days) after implantation and in 5% of the controls (2/42) ( P < .0001). None of the abnormalities were noted on the official reports. Among subgroups, chest radiographs were abnormal for the following indications: pacemaker dysfunction in 4 of 7 patients versus 0 of 21 controls ( P = .0017), extracardiac stimulation in 1 of 3 patients vs 0 of 9 controls ( P = .25), and lead perforation and/or displacement in 3 of 4 patients vs 2 of 12 controls ( P = .06). Conclusions Chest radiographs are useful after pacemaker placement and demonstrate the majority of complications that require reoperation. Familiarity with the expected normal position of the leads, appearances of pacemaker complications, and comparison with prior radiographs is crucial in rendering a correct diagnosis that guides patient management.