Piercing the left lung with a pacemaker lead,an uncommon complication

Although percutaneous insertion of pacemaker leads is a simple and safe method, it remains a procedure with a relatively high complication rate. We describe an uncommon and avoidable complication of this technique: piercing the lung with a pacemaker lead in an obese patient after direct puncture of the subclavian vein.     

Percutaneous transcatheter repositioning of displaced permanent pacemaker atrial lead with a simple system

A 48-year-old man who was implanted with a DDD-R pacemaker because of sick sinus syndrome eight days ago presented to our institute with a syncopal attack. Fluoroscopy showed a dislodged active fixation atrial pacemaker lead. With a snare system simply improvised from a 0.014 inch guidewire and a NIH catheter, the lead was repositioned via percutaneous transfemoral approach. The procedure was easy and completed without any complication. Follow-up controls after two weeks and three months showed stability of the lead position with normal pacing and sensing functions.     

Pacemaker Lead Induced Inferior Vena Caval Thrombosis Leading to Portal Hypertension

Inferior vena caval thrombosis is an unusual complication of permanent pacemaker implantation. The clinical presentation due to thrombosis depends on the site of thrombus. We have described here a rare case of pacemaker lead associated thrombosis of inferior vena cava, its diagnostic work up and briefly reviewed the existing literature of this uncommon complication.     

Successful percutaneous retrieval of unusually knotted temporary pacemaker lead

Implantation of temporary pacemaker lead is commonly performed procedure and is usually safe, but can sometimes develop rare and serious complication like intracardiac lead knotting which may require challenging retrieval techniques. We report a case of successful percutaneous retrieval of unusually knotted right internal jugular venous temporary pacing lead via left femoral transvenous approach using snare over a long sheath after cutting the electrode proximally and thus avoiding any surgical intervention.     

Alternate method for endocardial pacemaker lead implantation: A hybrid mini-thoracotomy approach

Although the conventional methods for endo-cardial pacemaker lead implantation via subclavian or cephalic or axillary vein routes is common, but sometimes due to anatomical variations it is not feasible to access these veins Emergence of newer techniques are useful for lead implantation. This case report focuses on a hybrid approach of combined mini-thoracotomy for endocardial pacemaker lead implantation. This fluoroscopy guided minimal thoracotomy approach with endocardial MRI compatible lead placement had the benefits of simple procedural, minimal hospital stay, low early complication rates and economically viable to the patient.     

Pneumothorax resulting from subclavian puncture: a complication of permanent pacemaker lead implantation

Pneumothorax is a mild complication during pacemaker lead implantation using the subclavian puncture technique. We report on five-year experience in 433 pacemaker lead implantation procedures in 379 patients. The cephalic vein route was solely used in twelve patients. Three procedures were performed over time in four patients and one patient needed four repetitive punctures for pacemaker lead implantation and replacement. Thus 421 punctures were carried out in 367 patients. Eleven case of pneumothorax were observed: in eight patients (1.9%) a partial pneumothorax occurred and in three patients (0.7%) the pneumothorax was nearly complete. In the latter patients a chest tube was inserted and hospital admission was prolonged for 3, 6 and 6 days, respectively. Old age with a corresponding abnormality in the form of chest deformation were predominantly found in the patients with this type of complication.     

Hemoptysis--a rare complication of pacemaker implantation

We describe a case of hemoptysis as a rare complication of pacemaker lead insertion via the axillary approach in a patient with difficult chest anatomy.     

Inadvertent Transarterial Lead Placement in the Left Ventricle and Aortic Cusp: Percutaneous Lead Removal with Carotid Embolic Protection and Stent Graft Placement

Background/PurposeTransarterial lead implantation in the left ventricle or aorta is a rare complication. Percutaneous lead removal is associated with significant thromboembolic and bleeding risk. We present two cases of lead removal from the left ventricle via the left subclavian artery with concurrent carotid embolic protection followed by stent graft placement in the subclavian artery.Methods/ResultsPatient 1 underwent prior pacemaker implant with atrial and ventricular active fixation leads positioned in the right coronary cusp and the left ventricle, respectively. Patient 2 had prior ICD implant with a single active fixation lead positioned in the left ventricular apex. Lead removal was performed in a hybrid operating room. Distal embolic filter wires were deployed in the carotid arteries following anticoagulation. Intravascular ultrasound of the left subclavian artery was performed and as the leads were withdrawn, a covered stent was deployed at the removal site. Final angiography demonstrated no evidence of embolic phenomena. Both patients underwent transvenous lead implantation followed by an uneventful postoperative clinical course.ConclusionsTransarterial percutaneous lead removal may be safely performed using embolic filter protection of the cerebral circulation and stent graft placement of the arterial entry site.     

Pacemaker lead endocarditis: A rare diagnosis with a varied presentation

We present a patient with a pacemaker lead endocarditis who showed no signs of pocket infection but with high fever and signs of infection in the routine laboratory tests. A diagnosis of pacemaker lead endocarditis must be considered in all patients with fever and infection parameters who have a pacemaker inserted, not only in the first weeks after implantation but also late after implantation, as long as no other cause of infection has been found. Transthoracal echocardiography alone is not sensitive enough to establish the correct diagnosis. Transoesophageal echocardiography (TEE) is mandatory to demonstrate the presence or absence of a vegetation on a pacemaker lead.     

Delayed presentation of pacemaker Reel Syndrome and lead damage: Coincidence or consequence?

Reel syndrome is a pacemaker lead early dislodgment, characterized by reeling-in of the lead(s) without being damaged. We herein present a case of an 86-year-old woman, with medical history of single chamber pacemaker implantation two years ago, admitted in cardiology department with complete AV block. Chest-Xray revealed ventricular lead coiling around and behind the pacemaker device. Urgent extraction of the previous pacemaker was performed; however, the lead damage made its repositioning unfeasible. Successful implantation of single-chamber pacemaker has been made. This clinical case highlights the importance of adequate follow-up to timely identify lead dislodgement, avoid lethal complications and lead fracture.     

An unexpected complication of intracardiac device implantation: Contralateral pneumothorax and pneumopericardium

A 62-year-old man developed concomitant right-sided pneumothorax and pneumopericardium after undergoing implantation of a left-sided dual-chamber pacemaker. The case is reported for its rarity. The possible mechanisms and management options for this extremely rare complication are discussed.     

Left ventricular giant pseudoaneurysm

Left ventricular (LV) pseudoaneurysm is a rare complication of myocardial infarction. It may also occur as a complication of mitral valve surgery, chest trauma, and bacterial endocarditis. It forms when a cardiac rupture contains adherent pericardium or scar tissue and is typically located on the posterior or inferior LV wall. Pseudoaneurysms have a propensity to spontaneous rupture; hence, immediate surgical intervention is the treatment of choice for LV pseudoaneurysms diagnosed in the first months after myocardial infarction. The management of chronic LV pseudoaneurysms is still a subject of debate.     

Inadvertent Lead Placement In The Left Ventricle: A Case Report And Brief Review

Inadvertent lead placement in the left ventricle (LV) is an uncommon and often under-diagnosed complication of cardiac device implantation. Thromboembolic (TE) events are common and usually secondary to fibrosis or thrombus formation on or around the lead. Anticoagulation can prevent TE events. Percutaneous and surgical LV lead extractions have been performed successfully, but the risks of percutaneous lead removal are not well-defined. In this report, we describe a case of inadvertent LV lead placement and briefly review the contemporary literature.     

Special problems of pacing in children

The number of children suffering from congenital or acquired rhythm disorders, and therefore being pacemaker dependent, is very small. This is one of the reasons why a special hardware has never been developed for this cohort. Pacemaker implantation into children does not differ substantially from operations in adults. But there are several important points which have to be fulfilled in these small patients in order to guarantee a complication free function. As most of these children remain pacemaker dependent a lifetime, it is of tremendous importance to minimize all revisions regarding the implanted systems and to enable our small patients a high and therefore nearly normal quality of life. Pros and cons of different surgical approaches, implantation sites and the problem of growth after pacemaker implantation in children are considered.     

Balloon Venoplasty of Subclavian Vein and Brachiocephalic Junction to Enable Left Ventricular Lead Placement for Cardiac Resynchronisation Therapy

This report describes the successful implantation of a LV lead using balloon venoplasty to overcome a very tight stenosis of the right subclavian vein / brachiocephalic junction for cardiac resynchronisation therapy (CRT-P) in a patient with a right sided CRT-P system and a failed epicardial LV lead. It is important for device implanters to be familiar with interventional equipments and techniques such as balloon venoplasty to overcome difficult venous access.     

Halo-shape technique for leadless pacemaker implantations: A case report

A 92-year-old woman underwent an implantation of a leadless pacemaker (Micra; Medtronic, Inc, Minneapolis, MN) for complete atrioventricular block after a transvenous lead extraction due to a pocket infection of a dual chamber pacemaker. Marked scoliosis and a humpback due to an advanced age made it impossible to direct the tip of the pacemaker delivery catheter towards the right ventricular septum or apex and shape the catheter into a gooseneck-shape. Thus, by attaining a halo-catheter shape of the delivery catheter, the catheter tip could be directed toward the infero-basal portion of the right ventricular septum. The pacemaker was successfully deployed at that site without any complications, and good device parameters were achieved. The halo-shape technique may be also an alternative method for delivering a leadless pacemaker in patients with an unsuccessful delivery of a leadless pacemaker to the right ventricular septum using the conventional gooseneck-shape technique.     

Right bundle branch block pattern after uncomplicated right ventricular outflow tract pacing in a patient with a left sided superior vena cava and corrected tetralogy of Fallot

Usually an electrocardiogram after right ventricular (RV) pacing should yield left bundle branch block (LBBB) pattern. However, the presence of right bundle branch block (RBBB) pattern after pacemaker implantation should alert the physician to a malposition of lead. We report a case of 18-year-old female who underwent dual chamber pacemaker implantation and had RBBB pattern post implantation. Detailed evaluation revealed an uncomplicated right ventricular outflow tract pacing. The possible causes of this abnormal pattern after an uncomplicated RV pacing are also reviewed.     

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

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.     

A subpectoral pocket in the management of a patient with impending extrusion of a pulse generator

A new method of management of the extruding cardiac pacemaker is proposed. The technique involves placement of the pacemaker and its leads in a subpectoral pocket. The technique has been studied in 13 patients with a success rate of 84.6 percent, perioperative complication rate of 7.7 percent, and late extrusion rate of 7.7 percent.     

Transvenous pacing through the pulmonary valve in a patient with cyanotic congenital heart disease after Glenn shunt – A case report

Bradyarrhythmia requiring pacing is infrequently encountered in patients with complex cyanotic congenital heart disease. Even though epicardial pacing is the preferred mode, rarely, a need for endocardial lead implantation arises.Patients with cavopulmonary shunts limit access to the venous atria and ventricles, necessitating alternate methods of pacemaker implantation. We report transvenous endocardial lead implantation by an unconventional method in a patient with congenitally corrected transposition of great arteries after a bidirectional Glenn shunt.