Download Late perforation of a defibrillator lead managed by percutaneous

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doi:10.1093/europace/eun376
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Late perforation of a defibrillator lead managed by percutaneous,
intravenous extraction
Baskar Sekar1, Luke Tapp1, Shajil Chalil2, Howard Marshall3, and Francisco Leyva4*
1
Department of Cardiology, Good Hope Hospital, Sutton Coldfield, UK; 2Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK; 3Queen Elizabeth
Hospital, Birmingham, UK; and 4Department of Cardiology, University of Birmingham, Good Hope Hospital, Heart of England NHS Foundation Trust, Rectory Road, Sutton
Coldfield, West Midlands B75 7RR, UK
* Corresponding author. Tel: þ44 121 4249369, Fax: þ44 121 4247804, Email: [email protected]
Received 23 September 2008; accepted after revision 8 December 2008
We report the case of a patient with ischaemic cardiomyopathy who underwent cardiac resynchronization therapy with defibrillator
back-up. He re-presented 3 weeks later with chest pain, having received two shocks. We describe a case of late perforation with the
Riata lead causing inappropriate shocks.
Introduction
A 76-year-old man with symptomatic heart failure due to ischaemic cardiomyopathy underwent implantation of a cardiac resynchronization therapy device with defibrillator back-up for the treatment of heart failure and primary prevention of sudden cardiac death. A
post-procedure chest radiograph showed correct positioning of the leads. Three weeks later, he experienced pain and tenderness in
the left pectoral region and reported having received two shocks. Device interrogation revealed that shocks had been delivered during
sinus rhythm. High-frequency noise, most likely to be myopotentials from pectoral muscles, had been interpreted by the device as
ventricular fibrillation (Figure 1) and hence therapy was delivered. The high-frequency signals were reproduced by left arm flexion.
A chest radiograph revealed that the tip of the defibrillator lead (St Jude Medical Riata ST 7 Fr dual coil 65 cm lead) had perforated
through the right ventricular wall and migrated to the left intercostal muscles (Figures 2 and 3). Echocardiography demonstrated that
Figure 1 An electrogram showing high-frequency ventricular-sensed potentials, most likely to be pectoral myopotentials. These were
interpreted as ventricular fibrillation and a shock was delivered.
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: [email protected].
Figure 2 Postero-anterior chest radiograph demonstrating the cardiac resynchronization therapy with defibrillator device with adequate right atrial and left ventricular lead positions. The tip of the right ventricular lead lies beyond the cardiac silhouette, within the
pectoral muscle.
Figure 3 Lateral chest radiograph demonstrating the cardiac resynchronization therapy with defibrillator device with adequate right
atrial and left ventricular lead positions. The tip of the right ventricular lead lies beyond the cardiac silhouette, within the pectoral muscle.
the lead was traversing an area of high signal, possibly haematoma, within the anterior pericardial space. There were no clinical or
echocardiographic signs of pericardial tamponade. He was referred for lead extraction, which was carried out with a cardiac surgical
team on standby. The right ventricular lead was successfully extracted percutaneously, and a new lead (Medtronic 6943 lead) was
implanted without complication. The patient was discharged well the following day.
One month later, the patient was well and both generator and lead parameters were satisfactory, with no further episodes of highfrequency ventricular-sensed events.
Discussion
Although there is a small incidence of perforation with any endocardial pacing wire, there have been several reports of perforation
with the Riata ST implantable cardioverter defibrillator (ICD) lead.1 – 3 Cases of acute perforation in association with the Riata lead
have been reported, but of particular concern are the reports of delayed perforation several weeks after implantation, by which
time the lead tip may have migrated beyond the right ventricular free-wall.2,3
The incidence of Riata lead perforation ranges from 0.344 to 2.5%.3 Perforation may relate to operator factors as well as to characteristics, including tip stiffness and pressure (4.5 psi), and small tip diameter.2 Perforation has been more frequently reported with the
passive-fixation rather than with the active-fixation lead.4 The presence of the Optim insulation material,4 a hybrid material that combines the biostability and flexibility of silicone rubber with the strength, tear, and abrasion resistance of polyurethane, has also been
associated with a higher rate of perforation, although the reason for this is not immediately apparent.
We have described a case of late perforation of a Riata ICD lead 3 weeks after implantation. This case illustrates how lead perforation can occur long after implantation. A chest radiograph should be considered in patients with high-frequency ventricular-sensed
episodes, particularly in patients with Riata leads. We suggest that patients are carefully observed following implantation, and patients
are advised to report unexpected chest pain or shock therapy as this may result from lead perforation rather than ventricular
arrhythmias.
Conflict of interest: none declared.
References
1. Danik SB, Mansour M, Singh J, Reddy VY, Ellinor PT, Milan D et al. Increased incidence of sub-acute lead perforation noted with one implantable cardioverter-defibrillator.
Heart Rhythm 2007;4:439 –42.
2. Vlay SC. Concerns about the Riata (St Jude Medical) ICD lead. Pacing Clin Electrophysiol 2008;31:13 –5.
3. Lloyd MS, Shaik MN, Riley M, Lang Berg JL. More late perforations with the Riata defibrillator lead from a high-volume center: an update on the numbers. Pacing Clin
Electrophysiol 2008;31:784 –5.
4. Performance of St Jude Medical Riata ICD leads. www.marketwatch.com/news/story/results-studies-evaluating-high-voltage-lead/story (31 July 2008, date last accessed).