Interactive Cardiovascular and Thoracic Surgery 2:624-625(2003)
© 2003 European Association of Cardio-Thoracic Surgery
An unusual travel of an endocardial pacing lead to the left ventricle
Salvador Ninot*,
Gemma Sánchez and
Carlos-A. Mestres
Department of Cardiovascular Surgery, Hospital Clínic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
* Corresponding author. Tel.: +34-93-227-5515; fax: +34-93-227-5749
sninot{at}clinic.ub.es
Received April 10, 2003;
received in revised form July 29, 2003;
accepted July 30, 2003
 |
Abstract
|
|---|
A 80-year-old lady was admitted because of dyspnea, complete AV block and ventricular rate of 15 bpm. A DDDR pacemaker was successfully implanted. Postoperative EKG showed right bundle branch block and X-ray the ventricular lead in the left ventricle. It traveled all the way through a foramen ovale being later relocated in the right apex.
Key Words: Pacemaker; Endocardial lead; Left ventricle
|
1. Introduction
|
|---|
Permanent pacemaker with transvenous lead implantation is routinely practiced worldwide by cardiovascular surgeons, cardiologists, intensivists and general surgeons depending upon the type of institution where patients are diagnosed and treated. Despite thousands of implants it can be said that acute complications are relatively rare. Dislodgement of the lead tip, hematoma and pocket infection are the most frequently seen [1].
Malposition of pacing leads is a rare event although its actual incidence is probably unknown. However and despite intraoperative fluoroscopy control, malposition of the lead may occur and go unrecognized at the time of implantation. Although this has been reported in the past [2–7], we though useful to remind that this complication may eventually occur. Peripheral embolization seems to be the worst complication provided the lead follows an unexpected path and is wrongly placed in the apex of the left ventricle (LV). Prompt recognition and relocation of the lead must be performed.
|
2. Case report
|
|---|
A 80-year-old female patient was admitted to the emergency department with the chief complaint of progressive dyspnea of 3 weeks duration. She had past history of hypertension and diabetes mellitus on oral therapy. On admission she presented with ortopnea, jugular vein distention and bibasal rales. There were no murmurs nor pitting edema. Blood pressure was 160/80. EKG showed a left bundle branch block pattern and a ventricular rate of 15 bpm. Biochemistries were: creatinine 1.4 mg/dl, glucose 189 mg/dl and coagulation screening with normal limits. Chest X-ray showed cardiomegaly and pulmonary venous hypertension. Transthoracic echocardiogram with colour-flow mapping and Doppler analysis disclosed moderate LV dilatation with severe reduction of ejection fraction (30%) because of anterior-septoapical aneurysm and inferior akinesis. There was moderated mitral regurgitation due to calcific mitral annulus. There was moderate pulmonary artery hypertension. The diagnosis was made of dilated cardiomyopathy of probable ischemic origin, presenting with severe signs of congestive heart failure.
A DDDR permanent pacemaker with transvenous lead was indicated and implanted under routine fluoroscopic control in the electrophysiology room. After the implantation developed acute pulmonary edema. The review of the chest X-rays revealed an abnormal route of the lead (Fig. 1). A new echocardiogram confirmed that the lead crossed the foramen ovale and was implanted in the LV apex. Intravenous digitalis and diuretics were also started and the patient's condition markedly improved. Forty-eight hours later relocation into the right ventricular apex was performed in the operating room. Beta-blockers and ACE-inhibitors were associated and the patient was discharged on the 9th day after the implantation.
View larger version (127K):
[in this window]
[in a new window]
|
Fig. 1 Abnormal ventricular lead route through the atrial septum to the apex of the left ventricle (arrows).
|
|
|
3. Comment
|
|---|
Malposition of a ventricular lead is an uncommon event. However, its actual incidence may be underestimated because of underreporting. Transvenous leads are usually located in the right ventricular apex. Unadvertent transit of a transvenous lead through a patent foramen ovale or just by perforating the atrial septum can lead to a wrong positioning in the left atrium or in the LV apex. This may happen in largely dilated hearts like in those patients suffering from cardiomyopathy in which abnormal ventricular dimensions can make fluoroscopic examinations difficult leading to misinterpretation by the implanting physician. As it has been described, cardioembolic complications may appear which may eventually result in significant morbidity or even mortality. We were lucky enough to promptly recognize lead malposition and immediate relocation was performed. The patient had an uneventful recovery.
The suggested route through a patent foramen ovale or perforated atrial septum may be difficult to identify as any sign or symptom leading to recognition of such a malposition. The message is that we would like to draw the attention to this potentially serious complication that may happen even in the most experienced hands and stimulate discussion with this regard.
doi:10.1016/S1569-9293(03)00185-3
|
References
|
|---|
- Kazama S, Nishiyama K, Machii M, Tanaka K, Amano T, Nomura T, Ohuchi M, Kasahara S, Nie M, Ishihara A. Long-term follow up of ventricular endocardial pacing leads. Complications, electrical performance, and longevity of 561 right ventricular leads. Jpn J Heart J. 1993;34:193–200
- Dalvi BV, Rajani RM, Lokhandwala YY, Sathe SV, Kulkarni HL, Kale PA. Unusual case of pacemaker lead migration. Cathet Cardiovasc Diagn. 1990;21:95–96[Medline]
- Ghani M, Thakur RK, Boughner D, Morillo CA, Yee R, Klein GJ. Malposition of transvenous pacing lead in the left ventricle. Pacing Clin Electrophysiol. 1993;16:1800–1807[CrossRef][Medline]
- Sharifi M, Sorkin R, Lakier JB. Left heart pacing and cardioembolic stroke. Pacing Clin Electrophysiol. 1994;17:1691–1696[CrossRef][Medline]
- Raghavan C, Cashion WR Jr, Spencer WH 3rd. Malposition of transvenous pacing lead in the left ventricle. Clin Cardiol. 1996;19:335–338[Medline]
- Arbane M, Schlapfer J, Aebischer N, Kappenberger L. Recurrent cardioembolic stroke related to late dislodgement of a right atrial pacing lead into the left atrium. Europace. 1999;1:202–205[Abstract/Free Full Text]
- Agnelli D, Ferrari A, Saltafossi D, Falcone C. A cardiac embolic stroke due to malposition of the pacemaker lead in the left ventricle. Ital Heart J. 2000;1(Suppl. 1):122–125[Medline]
|
|
Top
Abstract
1. Introduction