Cerebral Embolism Due to a Retained Pacemaker Lead: A Case Report

Cerebral Embolism Due to a Retained Pacemaker Lead: A Case Report A D A M B O H M . FERENC B A N Y A I . K A T A L I N K O M A R O M Y , * and I S T V A N P R E D A

ARNOLD PINTER.

Erom the Cardiovascular Center and the *Departmont of Radiology, Imre Haynal University of Health Sciences, Budapest. Hungary BOHM, A, ET AL.: Cerebral Embolism Due to a Retained Pacemaker Lead: A Case Report. There are only

a few reported cases of a pacemaker lead migrating inadvertently into the left atrium or ventricle. An unusual complication of unremoved, unwanted pacemaker lead is presented. The free tip of the lead caused cerebral embolism after perforating the interatrial septum. (PACE 1998; 21:629-630) retained lead, cerebral embolism

Case Report

Discussion

A VVI pacemaker (Biovallees 703) with transvenous lead (Biovallees 703) was implanted into a 59-year-old male patient who presented with carotid sinus syndrome 7 years ago. Exit block developed 6 montbs later, probably due to improper lead position. The lead was cut short, left in place, and substituted with a Siemens ACF 423 lead. Despite chronic platelet aggregation inhibition treatment, cerebral embolism demonstrated by computed tomography scan occurred. At that time, the patient was referred to our clinic to locate the source of embolism. Transesophageal echocardiographic study showed tho unremoved lead crossing the interatrial septum from the right atrium into the left atrium. The complete, abnormal course of tbe lead was demonstrated by lateral X ray. From the distal tip fixed in the rigbt ventricular inflow tract instead of the right ventricular apex, the unremoved lead formed a loop in the pulmonary artery, returned to the right ventricle, went to the right atrium, crossed the interatrial septum by perforating it, and, from the left atrium, the free tip went to the upper left pulmonary vein (Fig. 1). The lead was removed by cardiopulmonary bypass. Intraoperative findings confirmed the diagnosis. The free tip of the lead was found to bo extensively covered witb tbrombus.

Despite the large number of pacemaker implantations, only a few cases of lead malpositions in the left atrium or ventricle have been reported. This complication probably occurs more frequently than is seen, but many cases may remain undiagnosed.^ The pacemaker lead may enter the left atrium or ventricle via atrial septal defect,^ open foramen ovale,^ sinus venosus defect,** or ventricular septal defect.^ There also are case reports of lead malposition in the left ventricle due to inadvertent transarterial lead introduction.^ In our case, an unremoved, unwanted pacemaker lead migrated into the left atrium and, finally, into the pulmonary vein by perforating the interatrial septum. Unremoved, sterile pacemaker leads seldom cause any complication, although a case of hemopericardium due to right ventricular perforation by the free tip of the lead has been reported.^ Unremoved leads may irritate tbe right ventricle, leading to serious ventricular arrhythmias, or they may be a source of pulmonary embolism.^ Pacemaker lead in the left atrium or ventricle may lead to serious complications, although accidental left ventricular stimulations for 2,'^ 7,'^ or even 17 years'* have been reported. The risk of tbromboembolic complication is high and may produce various neurological symptoms from amaurosis fugax to aphasia and hemiplegia.'" Cerebral embolism also occurred in our case of lead malposition into pulmonary vein.

Address for reprints; Adam Bohm, M.D., Cardiovascular Center. Imre Haynal University of Health Sciences. Budapest S7.abok:su.33.. H-n35 Hungary. Fax: 36-1-270-2011. Received Auf^usi 5.1997: accepted August 13. 1997.

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Posteroanterior and lateral chest X ray is essential during pacemaker implantation and follow-up. However, lateral c;hest X ray often is neglected,^ although lead malposition t:au be identified easily by this method.^^^" Two-dimensional echocardiography also is helpful in the detection of lead malposition.' If perforation or lead malposition to the left atrium or ventricle is suspected, transesophageal echocardiograpby is indicated.^" This metbod demonstrated perforation of the interatrial septum by the pacemaker lead in our case. Opinions on the treatment of lead malpositions are controversial. Some authors suggest only platelet aggregation inhibition treatment,^ since cases of long-term uncomplicated left ventricular pacing have been reported.^•'*'' Others strongly suggest anticoagulant treatment, since Ihromboembolic events may occur despite platelet aggregation inhihition treatment,'* such as in our case. Removal of the pacemaker lead in malposition is suggested if a tbromboembolic event has occurred and the patient can tolerate open heart surgery.''" Open heart surgery is preferable since it allows revision of the left ventricular structures and safe removal of the (sometimes extensive) thrombotic appositions.^ Figure 1. Lateral chest X ray. A shortcut retained lead (dotted line) and a functioning lead in correct position. See text for details.

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