Management of Inadvertent Left Ventricular Permanent Pacing

Inadvertent malposition of a permanent ventricular lead into the middle cardiac vein was misdiagnosed as lead perforation

A 54‐year‐old man had a dual‐chamber pacemaker implantation 9 years ago because of sick sinus syndrome at a different facility. The patient did not undergo any evaluation of his pacemaker for a long time with cardiologist. The patient was admitted to another hospital manifesting dyspnea and palpitation with atrial fibrillation for 1 month, and he was diagnosed with ventricular lead perforation. For further treatment, he was referred to our hospital, and an elective replacement indicator (ERI) of the battery state and a malpositioned ventricular lead into the middle cardiac vein were found. Finally, the pacing lead was left in the primary place and the pacemaker was replaced.

Inadvertent left ventricular pacing due to lead malpositioning, incidentally discovered seventeen years later

Inadvertent lead malpositioning into the left ventricle (LV) is an uncommon complication of pacemaker lead implantation. It can have implications on clinical outcome due to ventricular dyssynchrony, and result in further complications such as thrombus formation with subsequent embolisation. This case study reports the clinical, electrocardiographic, plain film and echocardiographic findings of an 82-year-old male in whom the intravenous lead of a dual chamber pacemaker was unintentionally passed into the LV via an atrial septal defect. Inadvertent placement was discovered incidentally following the onset of atrial fibrillation (AF) 17 years later.

Endocardial left ventricular pacing after accidental aortic wall perforation

Inadvertent endocardial placement of a pacing lead in the left ventricle through the aortic valve is a rare complication with an unknown incidence because of inadequate reporting. Reported cases are usually the result of lead insertion via the subclavian artery. A possible but very unusual situation is endocardial lead insertion in the left ventricle after aortic arch perforation. We report the case of a 72-year-old woman in whom a screw-in pacing lead accidentally perforated the aortic arch and continued its way through the ascending aorta, aortic valve and left ventricle, after insertion through the left subclavian vein. We describe how this complication was diagnosed, the predisposing factors, the risks it carries and the ways in which devastating consequences have so far been avoided, as the patient refused any surgical intervention including lead removal.

Percutaneous extraction of inadvertently placed left-sided pacemaker leads with complete cerebral embolic protection

Lead wire malposition is a known, but rare complication of permanent pacemaker or defibrillator implantation. The actual incidence and prevalence is unknown and management options for inadvertent left ventricular lead malposition have not been uniform. Current recommendations include systemic anticoagulation with warfarin or surgical lead removal with circulatory arrest for compelling clinical scenarios. Percutaneous left-sided lead extraction is contraindicated due to the potentially increased risk of thromboembolic complications associated with this procedure. To our knowledge, this is the first report of percutaneous extraction of inadvertently placed left ventricular and left atrial endocardial pacemaker leads with flow-preserving complete cerebral embolic protection. We also review the current literature regarding the incidence, management, and percutaneous extraction of left-sided cardiac leads.

An unusual cause of transient ischemic attack in a patient with pacemaker

Pacemaker lead malposition in various locations has been described in the literature. Lead malposition in left ventricle is a rare and an underdiagnosed complication. We present a 77-year-old man with history of atrial fibrillation and pacemaker placement who was admitted for transient ischemic attack. He was on aspirin, beta blocker, and warfarin with subtherapeutic international normalized ratio. His paced electrocardiogram showed right bundle-branch block, rather than the typical pattern of left bundle-branch block, suggesting pacemaker lead malposition. Further, his chest X-ray and echocardiogram confirmed the pacemaker lead position in the left ventricle instead of right ventricle. He refused surgical removal of the lead and we increased his warfarin dose. Diagnosis of lead malposition in left ventricle, though easy to identify in echocardiogram, requires high index of clinical suspicion. In asymptomatic patients, surgical removal may be deferred for treatment with lifelong anticoagulation.

Inadvertent implantation of pacemaker lead in the left ventricle: kill two birds with one stone

We report an asymptomatic patient in whom the intravenous pacemaker (PM) lead was inadvertently implanted in LV through the perforated interventricular septum. He had no embolic events during the last 9 years after the implantation. Possible explanation of the uncomplicated follow-up period is that the patient had been taking warfarin because of mechanical mitral valve prosthesis.

Management of symptomatic inadvertently placed endocardial leads in the left ventricle

BACKGROUND

There are limited data regarding the clinical care of inadvertently placed endocardial leads in the left ventricle (LV). We clarified the appropriate management within the context of our experience and published literature.

METHODS

Hospital charts dating from October 2008 to December 2010 were reviewed at a high-volume cardiovascular tertiary referral center. Six patients were identified with inadvertently placed leads in the LV through an atrial septal defect.

RESULTS

Six patients (four males, two females) underwent LV lead removal, four through open surgical intervention and two percutaneously. Three (50%) patients presented with severe mitral regurgitation; one (16%) with a thromboembolic transient ischemic attack and two (33%) were asymptomatic. The mean age was 68.5 ± 8.48 years (55-78). Mean ejection fraction was 38.47 ± 11.1% (25%-50%). Four patients (66%) had a pacemaker and two (33%) had implantable cardioverter defibrillators. Comorbidities consisted of diabetes mellitus (50%), chronic renal failure (16%), severe chronic pulmonary hypertension (16%), and congestive heart failure (33%). Hypertension and coronary arterial disease were present in all patients. All patients had complete extraction or repositioning without intraoperative complications or mortality within 30 days. At 6-month follow-up, the patient with severe pulmonary hypertension died of pneumonia and the other five were alive and well.

CONCLUSION

The avoidance and early recognition of inadvertently placed endocardial leads in the LV is imperative in order to avoid potentially serious sequelae and invasive interventions. Treatment usually consists of surgical extraction, although anticoagulation and percutaneous simple traction techniques are an option in certain scenarios. 

Lead astray: minimally invasive removal of a pacing lead in the left ventricle

Pacemaker and implantable cardioverter defibrillator (ICD) leads are placed routinely with few notable complications. A rarely described complication of transvenous lead placement is malpositioning into the left ventricle. This situation can cause additional complications in the form of thromboembolic events. We present a case of a malpositioned left ventricular lead that was successfully removed with a minimally invasive technique.

[Stimulation probe, by involuntary transseptal ventricular trajectory]

The introduction in the left ventricle of a stimulation probe, by an involuntary ventricular transseptal trajectory can pass unobserved during the implantation and can be revealed later on occasion of complications. It is a rarely described possibility and can have some serious consequences. We discuss through our observation ways to avoid this trap of the definitive cardiac stimulation.

[Strategies for the avoidance and treatment of complications during pacemaker implantation]

The implantation of a pacemaker is the therapy of choice for symptomatic bradyarrhythmias. The perioperative complication rate is low. This article gives an overview on possible complications, their avoidance and treatment.

Left ventricular endocardial pacing: a transarterial approach

INTRODUCTION

We tested the feasibility of a new technique of direct left ventricular endocardial lead placement across the aortic valve in a chronic (six month) pig model. The potential for aortic valve damage, systemic embolization, and pacing lead maturation and function within the left ventricle are unknown.

METHODS

Ten minipigs were successfully implanted with a transaortic left ventricular lead (Medtronic CapSureFix, Minneapolis, MN, USA) placed in the left ventricular apex via the carotid artery. Each pig received either a polyurethane (n = 5) or silicone (n = 5) lead. Post implant each pig received clopidogrel and aspirin for seven days. After six months all surviving pigs underwent thorough necropsy.

RESULTS

Each pig had adequate sensing (12.1 +/- 4 mV) and pacing thresholds (0.79 +/- 0.2 @ 0.5 V) at implant. Postoperatively two pigs died of a respiratory illness. One pig died postoperatively due to sepsis. At the six-month follow-up, all surviving pigs (n = 7) were in a healthy state. Of the pigs without dislodgement (n = 5) there was adequate sensing, but a rise in pacing thresholds. Echocardiography revealed a normal ejection fraction and only trace to mild aortic insufficiency in all pigs. Of the seven surviving pigs there were no thromboembolic events noted. One silicone lead was noted to have thrombosis along the lead screw and shaft.

CONCLUSION

Direct transaortic placement of a left ventricular lead is feasible. After six months, there was no significant aortic regurgitation and no evidence of thromboembolism despite no anticoagulation. Lead function was acceptable and only one silicone lead (and no polyurethane lead) was noted to have significant thrombosis.

Diagnostic Value of the 12-Lead Electrocardiogram during Conventional and Biventricular Pacing for Cardiac Resynchronization

The paced 12-lead ECG is a valuable tool in the assessment of patients with pacemakers, and ideally should be recorded routinely at the time of implantation and during follow-up. It has become particularly important in patients undergoing cardiac resynchronization. The multiplicity of clinical situations described in this review highlight the pitfalls of using a single ECG lead in the overall evaluation of pacemaker patients. The design of programmers capable of registering a 12-lead ECG would obviate the need of an additional electrocardiograph and encourage the routine recording of the paced 12-lead ECG with each patient encounter. Such an arrangement would improve the care of pacemaker patients.

Two-Dimensional Echocardiography for the Diagnosis of Interventricular Septum Perforation by a Temporary Pacing Catheter

This case study describes a patient with complete heart block inadvertently paced from the left ventricular posterior wall due to perforation of interventricular septum by a temporary pacing catheter. This is a rare but potentially fatal complication of pacing. The frontal chest radiograph neither identified abnormalities nor could determine the exact site of the catheter tip. The electrocardiogram revealed a right bundle branch block pattern. Echocardiography was performed immediately at bedside and the diagnosis was made. The temporary pacing catheter was removed without complications and, the next day, the patient underwent permanent pacemaker implantation. Given its noninvasiveness and availability, echocardiography is a highly effective means of assessing pacemaker complications such as catheter perforation.

Right ventricular enlargement mimicking electrocardiographic left ventricular pacing

Electrocardiographic right bundle branch block morphology during cardiac pacing is occasionally the result of accidental placement of pacemaker or defibrillator leads into the left ventricle. Inadvertent lead placement in the left heart is associated with a risk of systemic embolism. Previous authors have attempted to define safe (right ventricular origin) and unsafe (left ventricular origin) patterns of right bundle branch block during pacing. We report a case of a patient with severe dilated cardiomyopathy and a correctly positioned pacemaker-defibrillator lead in the right ventricular apex, who meets electrocardiographic criteria for lead implantation into the left ventricle.

Accidental Transarterial Implantation of Dual Chamber Pacemaker Leads in the Left Ventricle and the Right Coronary Artery

Implantation of permanent pacemaker systems is associated with a low rate of complications. The case of a 72-year-old woman is described who suffered from a cluster of complications related to permanent pacemaker implantation. Besides major bleeding, requiring transfusion and pneumothorax, malposition of both pacemaker leads in the arterial system occurred, with the atrial lead screwed into the right coronary artery, with subsequent occlusion of the vessel and the ventricle lead placed in the left ventricle.

From lysosome to proteasome: the power of yeast in the dissection of proteinase function in cellular regulation and waste disposal

The yeast Saccharomyces cerevisiae has turned out to be an invaluable tool in the molecular biological sciences for elucidating the housekeeping functions of eukaryotic cells. Due to its easy amenability to biochemical, genetic, molecular biological and cell biological experimentation, including genomics and proteomics, yeast has become one of the most frequently used eukaryotic model organisms. One of the fields where studies in yeast have a truly pacemaking character is cellular control by proteolysis. The function of vacuolar (lysosomal) proteolysis was elucidated. The in vivo role of ubiquitin and its relation to the proteasome was uncovered. This research led to an avalanche of studies in many different eukaryotic systems, including mammals, and provided us with surprising new insights in cellular control in health and disease.