Download Pacing Lead Perforation on the Right Side of the Heart

Pacing Lead Perforation on the Right
Side of the Heart
S. Serge BAROLD M.D.*, Roland X. STROOBANDT M.D.**, Alfons F. Sinnaeve M.D.***
* Cardiology Division, University of South Florida College of Medicine, Tampa, Florida, USA.
** Department of Cardiology, Arrhythmia Unit, University Ghent, Ghent, Belgium.
Technical University Khbo, Department of Electronics, Ostend, Belgium
ABSTRACT
Cardiac perforation is a rare potentially serious and often unrecognized complication of pacemaker lead
implantation. In this paper, we present a case with pacing lead perforation on the right side of the heart.
K EYWORDS
Pacemaker lead, cardiac perforation, unipolar electrograms
Pacing Elektroduna Bağlı Kalbin Sağ Tarafında
Perforasyon
ÖZET
Kardiyak perforasyon, elektrot implantasyonunun çoğunlukla tanınamayan nadir fakat önemli bir komplikasyonudur. Bu yazıda, pacing elektroduna bağlı sağ kalp perforasyonu olan bir olgu sunulacaktır.
A NAHTAR K ELİMELER
Pacemaker elektrodu, kardiyak perforasyon, unipolar elektrogramlar
İLETİŞİM ADRESİ
S. Serge BAROLD, M.D.
S. Serge Barold MD. 5806 Mariner’s Watch Drive, Tampa FL 33615, USA.
Pacing Lead Perforation on the Right Side of the Heart
C
ardiac perforation is a rare potentially serious and often unrecognized complication of pacemaker lead implantation. It may occur at the time of implantation when it may cause hypotension from cardiac tamponade. Perforation usually does not lead to tamponade if the
lead is withdrawn and repositioned because the
perforation is often self-sealing.
The reported incidence of symptomatic perforation after initial implantation is about 1%.
The true incidence of perforation is not well
known because it may be subclinical and asymptomatic. Indeed CT scans in patients with uncomplicated pacing show a staggering 5% incidence of right ventricular perforation and 10%
in the case of atrial leads. Risk factors include female sex, increasing age, the use of stiff
stylets and active-fixation leads. Administration of oral steroid within 7 days preceding lead
implantation predisposes to perforation.
The clinical presentation of perforation has
changed and occurs later than in the past. The
use of active-fixation small body diameter leads
and implantable cardioverter-defibrillator leads
may be associated with increased risk for delayed right ventricular perforation. The late presentation is a less recognized complication of device implantation and may create an important
diagnostic problem with potentially catastrophic
consequences if unrecognized. The development
of small-diameter Subacute right ventricular perforation (several days or weeks after seemingly
uncomplicated implantation (usually up to 60
days after implantation and occasionally much
later) is a rare but serious complication of lead
implantation. Perforation can occasionally present after several months or a year.
After implantation, right ventricular perforation of the free wall may be recognized by pericardial pain, abdominal pain, dyspnea, synco-
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pe, friction rub, sinus tachycardia, increasing
ventricular pacing threshold, poor sensing, left
diaphragmatic stimulation (though this may also occur in the absence of perforation), intercostal muscle stimulation, pericardial effusion and
left hemothorax. Rarely perforation occurs into
the left ventricle through the ventricular septum.
Rare complications of RV lead perforation include lead migration into the peritoneal cavity, rib
perforation and damage to a left internal mammary graft to the left anterior descending artery
(with myocardial infarction). Also, the left anterior descending coronary artery (LAD) runs on
the epicardial surface of the heart within the interventricular groove superficial to the interventricular septum. From a pacing perspective, the
LAD lies at the junction between the septal and
anterior walls of the RV outflow tract. Therefore,
inadvertent lead placement on the anterior wall
or at the junction between anterior and septal
walls (rather than septal fixation) may endanger
the LAD with the helix of an active-fixation lead
and cause acute myocardial infarction.
The paced ECG may show a right bundle
branch pattern if the lead paces the left ventricle
usually from the pericardial space (Figure 1). The
chest X ray may show the lead beyond the cardiac shadow or a peculiar appearance not seen with
traditional uncomplicated right ventricular apical
placement (Figure 2). An echocardiogram and
CT scan should be performed to document lead
position. Transesophageal echocardiography is
superior to transthoracic echocardiography in delineating the entire course of a pacing lead. Difficulty in visualizing the lead in the right ventricle is not rare. The CT scan is particularly helpful
when echocardiography is equivocal. Multidetector computed tomography is emerging as the imaging modality of choice in diagnosing atrial and
ventricular lead perforation (Figure 3).
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Türk Aritmi, Pacemaker ve Elektrofizyoloji Dergisi
FIGURE 1
ECG showing a right bundle branch block pattern during VVI pacing with lead perforation of the right ventricular free wall. The
previous ECG had shown a left bundle branch pattern during pacing. On top the ventricular electrograms show a dominant R wave
from the tip (T) and proximal or ring electrode (R) consistent with perforation. A phonocardiogram on the right shows a pacemaker
sound (PS) consistent with perforation. B = bipolar.
FIGURE 2
FIGURE 3
Chest X ray showing unusual position of right ventricular
lead in a patient with lead perforation of the right ventricle
documented in Figure 3.
CT scan showing perforation of a right ventricular lead
These complications may lead to death if
they are not recognized early. In most patients,
the leads can safely be removed percutaneously
in the operating room under fluoroscopic gui-
dance and continuous EGM monitoring to confirm the diagnosis, with surgical backup support and together with TEE monitoring. Simple withdrawal of the lead is successful in 80%
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Pacing Lead Perforation on the Right Side of the Heart
of the cases. A stable asymptomatic perforation
can be left alone if pacing and sensing are satisfactory. If parameters are unsatisfactory, a stable asymptomatic perforated lead can be left in
place and a new lead implanted.
Diagnostic Value of the Unipolar
Electrogram
High levels of ST segment elevation (current of injury) in the unipolar tip electrogram
, greater than 10 mV at the time of implantation, were found to predispose to electrode perforation (Figure 4). With RV perforation the
unipolar EGM may show an upright complex
that looks like a standard precordial lead over
the lateral chest with disappearence of ST elevation. When the lead is gradually withdrawn,
some ventricular ectopy may occur as the lead
passes through the ventricular wall. Then, obvious ST elevation (current of injury) occurs
(Figure 5). This disappears when endocardial contact is lost. The intracavitary EGM often
shows a deep S wave followed by gradual reduction of its amplitude and P waves when the
lead lies in the right atrium.
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Recording of an adequate unipolar ventricular electrogram from the proximal RV electrode but an atypical one from the distal electrode should raise the suspicion of lead perforation
and so does the presence of ST elevation from
the proximal electrode and its absence from the
distal electrode. In the latter case, perforation
may be absent if the distal portion of the lead
is curled up and the tip points superiorly so that
endocardial contact occurs only via the proximal electrode.
Atrial Leads
Atrial (like RV) lead perforation can be delayed for weeks or much longer. Right atrial leads may perforate both pericardium and pleura, resulting in pericarditis, cardiac tamponade,
right–sided pneumothorax (associated with leftsided venous access), pneumopericardium (with
or without contralateral pneumothorax),. pneumomediastinum, isolated pneumopericardium
and rarely aortic laceration.
Successful and safe percutaneous lead withdrawal (except for aortic perforation) has been
reported and should be attempted on in the ope-
FIGURE 4
Unipolar electrogram from the tip of a passive fixation pacemaker lead. The marked ST elevation in relation to the QRS deflection
indicates myocardial wedging. Excessive wedging with marked ST elevation resembles a monophasic–like action potential. The S
wave disappears because the rapid and massive ST elevation gives the impression of a dominant R wave. Withdrawal of the lead by a
few millimeters restores the dominant negativity of the QRS part of the electrogram.
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Türk Aritmi, Pacemaker ve Elektrofizyoloji Dergisi
FIGURE 5
Unipolar tip electrogram of a perforated right ventricular lead. The electrogram was recorded continuously during gradual
withdrawal of the lead. On the top left, there is a tall R wave and slight ST elevation. Gradual withdrawal of the lead reduces the size
of the R wave and an rS pattern appears with prominent ST elevation as the lead traverses the myocardium. In the bottom tracing
the lead drops into the right ventricle whereupon the ST elevation disappears and the QRS morphology becomes consistent with an
intracavitary recording.
rating room under transesophageal echocardiographic guidance. Surgery is popular based on
the belief that a non-surgical approach is more
likely to cause bleeding as the wall of the right
atrium is thin and non-muscular.
Recurrent postcardiac injury syndrome in
the absence of perforation (diagnosis by exclusion) should be considered in patients who, after
pacemaker lead insertion, develop hemorrha-
gic pleuro-pericardial effusion associated with
markers of inflammation. It may occur some
weeks after uncomplicated perforation at the
time of initial implantation. Cardiac tamponade is rare. A pericardial window may be required and some workers advocate lead withdrawal. Indomethacin is useful therapy. This situation may lead to surgical exploration in the belief that perforation is present.
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