IJCA-18853; No of Pages 3 International Journal of Cardiology xxx (2014) xxx–xxx
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Letter to the Editor
An unexpected complication during percutaneous pacemaker lead extraction unveiled by transesophageal echocardiography Skevos Sideris a,⁎, Georgios Benetos b, George Lazaros b, Konstantinos Gatzoulis b, Dimitris Lymperiadis c, George Stavropoulos c, Konstantinos Toutouzas b, Konstantinos Manakos a, Konstantinos Traxanas a, Georgios Trantalis a, Dimitris Tousoulis b, Ioannis Kallikazaros a a b c
Cardiac Department, Hippokration Hospital, Athens, Greece First Department of Cardiology, Hippokration Hospital, Athens School of Medicine, Greece Department of Cardiac Surgery, Hippokration Hospital, Athens, Greece
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Article history: Received 7 September 2014 Accepted 20 September 2014 Available online xxxx Keywords: Ventricular perforation Percutaneous pacemaker lead extraction Right atrial thrombus Complication
Lead perforation in either the right atrium or ventricle is a rather uncommon event with published rates varying between 0.1–0.8% for pacemakers and 0.6–5.2% for implantable cardioverter-defibrillators (ICDs) [1]. Percutaneous lead extraction with surgical backup support is considered a safe and effective approach for the management of this complication [2]. Transesophageal echocardiography (TEE) is a useful tool for the surveillance of lead extraction and early recognition of unanticipated complications. This report describes a rare case of a patient with ventricular lead perforation, complicated by thrombus formation during lead extraction, which was detected with periprocedural TEE. A 50-year old male, with a history of sinus node dysfunction and syncope underwent dual-chamber pacemaker implantation using passive fixation leads in both right atrium and ventricle. No history of atrial fibrillation was reported. At the time of implantation all lead parameters were within normal limits (P wave 1.5 mV, R wave 7.5 mV and pacing threshold 1.2 mV). A chest X-ray 24-hours post-implantation, revealed pacemaker leads in proper position and the patient was accordingly discharged. Forty days later the patient presented with epigastric pain and pacemaker interrogation showed a slight increase in the stimulation ⁎ Corresponding author at: 114 Vasilissis Sofias Ave. 11527 Athens, Greece. Tel.: + 30 2132088000; fax: + 30 2107480660. E-mail address:
[email protected] (S. Sideris).
threshold. Although pain gradually subsided, in the following scheduled visits, further interrogation of the device revealed a progressive increase in the stimulation threshold, resulting in battery depletion two years after the first device implantation. Subsequent chest X-ray set the suspicion of the tip of the ventricular lead being out of the borders of the cardiac silhouette (Fig. 1A). Chest computed tomography confirmed the above finding, revealing additionally a small amount of pericardial fluid (Fig. 1B). Accordingly, percutaneous removal of the pacemaker lead was accomplished with cardiosurgical backup support, using a liberator locking stylet and telescoping dilator sheath under fluoroscopic guidance, without complications. Notably, periprocedural TEE was applied throughout the procedure for surveillance of the pericardial space. New leads were not implanted at this time. During the closure of the extracted pacemaker pocket, unexpectedly, TEE unveiled a large highly mobile echogenic structure of approximately 50 × 6.5 mm, extending from superior vena cava — right atrial junction into the right atrial cavity, compatible with thrombus. The mass did not interfere with tricuspid valve function and did not cause any flow acceleration in the superior vena cava (Fig. 2A, Video 1). During hospital stay, pericardial space monitoring with echocardiography did not show any fluid accumulation. A computed tomography pulmonary angiogram performed 2 days later did not reveal any pulmonary artery filling defects and a control for hypercoagulable states resulted negative. A 24-hour Holter recording before discharge revealed no significant rhythm abnormalities. The patient was initially treated with macromolecular intravenous heparin which was subsequently overlapped and finally replaced by oral anticoagulation with warfarin. The post-operative course was uneventful and he was discharged 1 week later. At his follow-up examination, two months later, the patient was doing well and a repeated TEE revealed total resolution of the right atrial thrombus (Fig. 2B, Video 2). This is a unique case of delayed pacemaker lead perforation, treated successfully with percutaneous extraction under TEE supervision, and unexpectedly complicated by right atrial thrombus formation. Percutaneous pacemaker lead perforation is considered to be acute when it occurs within 5 days after implantation, subacute when it occurs between 5–30 days and delayed when it occurs beyond 1 month after implantation [2]. Active fixation leads carry a higher risk for myocardial perforation and cases with ventricular perforation up to eight years after
http://dx.doi.org/10.1016/j.ijcard.2014.09.077 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Sideris S, et al, An unexpected complication during percutaneous pacemaker lead extraction unveiled by transesophageal echocardiography, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.09.077
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S. Sideris et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Fig. 1. Chest X-ray on initial presentation two years after the pacemaker implantation, setting the suspicion of the tip of the ventricular lead being out of the borders of the cardiac silhouette (arrow, panel A). Computed tomography scan showing protrusion of the ventricular lead in the epicardial fat (head of arrow), confirming the diagnosis. A small amount of pericardial fluid is also present (arrow).
implantation have been described [3–5]. Additional risk factors include temporary pacemaker insertion and steroid use [5]. However, the cases with delayed perforation by passive fixation leads are only a few. In the latter cases the time interval between implantation and perforation is less than one year [2]. Delayed lead perforation is often asymptomatic and characterized by a low rate of tamponade or death. Conservative approach to the management includes lead extraction under continuous TEE observation and provision of surgical back-up services. The insertion and stabilization of the ventricular lead on the septum rather than the free wall or apex, could potentially prevent RV perforation [2]. In the case presented it is not clear when the perforation occurred. The appearance of mild symptoms 40 days after implantation, which gradually subsided and the progressive increase in stimulation threshold with subsequent battery depletion could classify our case as delayed perforation. The right atrial thrombus formation was an unanticipated finding during the periprocedural TEE. Although pacemaker leads are potentially thrombogenic [6,7], the right atrial thrombus in our case was not in touch with the pacemaker leads. We might suppose that pacemaker's lead manipulation during the extraction procedure could have caused local superior vena cava trauma leading to throm-
bus formation. Interestingly superior vena cava thrombi extending into the right atrium have been occasionally detected with TEE in the setting of central venous catheters insertion and local injury related to the insertion procedure has been mentioned as the most plausible mechanism [8]. The treatment of right atrial thrombosis remains controversial. The size and site of the thrombus and the presence of symptoms are the main determinants of the proper treatment strategy. Therapeutic options include anticoagulation, thrombolysis and surgical extraction [9,10]. In the absence of any symptoms, significant tricuspid regurgitation or evidence of pulmonary embolism, a conservative approach with oral anticoagulation was adopted in this patient. In summary, this case focused on a patient with delayed lead perforation occurring after uneventful pacemaker implantation and successfully managed with percutaneous lead removal. Periprocedural TEE is of paramount importance for the early recognition of potentially life-threatening complications. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.09.077. Conflict of interest There is no reported conflict of interest.
Fig. 2. Periprocedural transesophageal echocardiography during pacemaker lead extraction (bicaval view), showing a large echogenic structure of approximately 50 × 6.5 mm extending from superior vena cava into the right atrial cavity (panel A). Transesophageal echocardiography (bicaval view), performed two months later, showing total resolution of the intraatrial mass (panel B).
Please cite this article as: Sideris S, et al, An unexpected complication during percutaneous pacemaker lead extraction unveiled by transesophageal echocardiography, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.09.077
S. Sideris et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Acknowledgment The authors of this manuscript have certified that they comply with the principles of ethical publishing in the International Journal of Cardiology. No external grant has been received for this article.
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Please cite this article as: Sideris S, et al, An unexpected complication during percutaneous pacemaker lead extraction unveiled by transesophageal echocardiography, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.09.077
