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Delayed lead perforation: can we ever let the guard down?

Alla VM, Reddy YM, Abide W, Hee T, Hunter C - Cardiol Res Pract (2010)

Bottom Line: Only about 40 such cases have been published, with the majority occurring <1 year after implantation.Through this report, we intend to highlight the increasing use of CRMD in elderly patients, and the lifelong risk of complications with these devices.Presentation can be atypical and a high index of suspicion is necessary for diagnosis.

View Article: PubMed Central - PubMed

Affiliation: Division of Cardiology, Creighton University Medical Center, Omaha, NE 68131, USA.

ABSTRACT
Lead perforation is a major complication of cardiac rhythm management devices (CRMD), occurring in about 1%. While most lead perforations occur early, numerous instances of delayed lead perforation (occurring >30 days after implantation) have been reported in the last few years. Only about 40 such cases have been published, with the majority occurring <1 year after implantation. Herein, we describe the case of an 84-year-old female who presented with recurrent syncope and was diagnosed to have delayed pacemaker lead perforation 4.8 years after implantation. Through this report, we intend to highlight the increasing use of CRMD in elderly patients, and the lifelong risk of complications with these devices. Presentation can be atypical and a high index of suspicion is necessary for diagnosis.

No MeSH data available.


Related in: MedlinePlus

Transthoracic echocardiogram in parasternal long axis view showing the large pericardial effusion. LV: left ventricle; RV: right ventricle; PCE: pericardial effusion.
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fig1: Transthoracic echocardiogram in parasternal long axis view showing the large pericardial effusion. LV: left ventricle; RV: right ventricle; PCE: pericardial effusion.

Mentions: An 84-year-old female presented with two episodes of transient loss of consciousness over 24 hours. She was initially evaluated in the emergency room of an outlying hospital where physical examination, electrocardiogram (ECG), and chest X-ray were unremarkable. Subsequently, she was transferred to our hospital for further evaluation. She denied chest pain, palpitations, dyspnea, or orthostatic dizziness. She was seated at the time of the index events, had no premonitory symptoms, and regained consciousness within a few minutes. Past medical history was significant for rheumatoid arthritis, paroxysmal atrial fibrillation, and symptomatic sinus pauses requiring a dual chamber pacemaker placement. The pacemaker (Medtronic, KDR901 Kappa DR; leads: Medtronic 5076 CapSure Fix Novus) was implanted in December, 2004 with the right ventricular lead in the apex and right atrial lead in the appendage. Her medications included warfarin, metoprolol, prednisone, and amiodarone. Pulse rate was 65/minute, blood pressure was 96/58 mmHg, and physical examination was significant for prominent jugular venous pulsations, and distant heart sounds. Metabolic panel and blood counts were normal and INR was therapeutic at 2.1. ECG revealed normal sinus rhythm without any abnormalities, chest X-ray demonstrated mild cardiomegaly with stable atrial/ventricular lead position and computed tomography scan of the head was unremarkable. Transthoracic echocardiogram revealed a large pericardial effusion with early echocardiographic signs of cardiac tamponade (Figure 1). Pacemaker evaluation revealed normal function; lead impedance, sensing and pacing thresholds were stable compared to evaluation 3 months prior. Previous echocardiogram, also done 3 months prior was unremarkable except for mild left ventricular hypertrophy. She underwent emergent surgical pericardiocentesis and about 600 mL of bloody fluid was drained. During the surgery, a defect in the right ventricular myocardium was visualized and repaired with sutures. The ventricular lead was in close proximity but there was no definite protrusion of the tip through the defect. A pericardial window was created and the right ventricular lead was successfully repositioned under transesophageal echo guidance. Pericardial fluid cultures were sterile, cytology was negative for malignant cells, and pericardial biopsy was normal. Further hospital stay was uneventful and she was discharged on her home medication regimen. She has had no recurrent symptoms or pericardial effusion at 1 year followup.


Delayed lead perforation: can we ever let the guard down?

Alla VM, Reddy YM, Abide W, Hee T, Hunter C - Cardiol Res Pract (2010)

Transthoracic echocardiogram in parasternal long axis view showing the large pericardial effusion. LV: left ventricle; RV: right ventricle; PCE: pericardial effusion.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2926653&req=5

fig1: Transthoracic echocardiogram in parasternal long axis view showing the large pericardial effusion. LV: left ventricle; RV: right ventricle; PCE: pericardial effusion.
Mentions: An 84-year-old female presented with two episodes of transient loss of consciousness over 24 hours. She was initially evaluated in the emergency room of an outlying hospital where physical examination, electrocardiogram (ECG), and chest X-ray were unremarkable. Subsequently, she was transferred to our hospital for further evaluation. She denied chest pain, palpitations, dyspnea, or orthostatic dizziness. She was seated at the time of the index events, had no premonitory symptoms, and regained consciousness within a few minutes. Past medical history was significant for rheumatoid arthritis, paroxysmal atrial fibrillation, and symptomatic sinus pauses requiring a dual chamber pacemaker placement. The pacemaker (Medtronic, KDR901 Kappa DR; leads: Medtronic 5076 CapSure Fix Novus) was implanted in December, 2004 with the right ventricular lead in the apex and right atrial lead in the appendage. Her medications included warfarin, metoprolol, prednisone, and amiodarone. Pulse rate was 65/minute, blood pressure was 96/58 mmHg, and physical examination was significant for prominent jugular venous pulsations, and distant heart sounds. Metabolic panel and blood counts were normal and INR was therapeutic at 2.1. ECG revealed normal sinus rhythm without any abnormalities, chest X-ray demonstrated mild cardiomegaly with stable atrial/ventricular lead position and computed tomography scan of the head was unremarkable. Transthoracic echocardiogram revealed a large pericardial effusion with early echocardiographic signs of cardiac tamponade (Figure 1). Pacemaker evaluation revealed normal function; lead impedance, sensing and pacing thresholds were stable compared to evaluation 3 months prior. Previous echocardiogram, also done 3 months prior was unremarkable except for mild left ventricular hypertrophy. She underwent emergent surgical pericardiocentesis and about 600 mL of bloody fluid was drained. During the surgery, a defect in the right ventricular myocardium was visualized and repaired with sutures. The ventricular lead was in close proximity but there was no definite protrusion of the tip through the defect. A pericardial window was created and the right ventricular lead was successfully repositioned under transesophageal echo guidance. Pericardial fluid cultures were sterile, cytology was negative for malignant cells, and pericardial biopsy was normal. Further hospital stay was uneventful and she was discharged on her home medication regimen. She has had no recurrent symptoms or pericardial effusion at 1 year followup.

Bottom Line: Only about 40 such cases have been published, with the majority occurring <1 year after implantation.Through this report, we intend to highlight the increasing use of CRMD in elderly patients, and the lifelong risk of complications with these devices.Presentation can be atypical and a high index of suspicion is necessary for diagnosis.

View Article: PubMed Central - PubMed

Affiliation: Division of Cardiology, Creighton University Medical Center, Omaha, NE 68131, USA.

ABSTRACT
Lead perforation is a major complication of cardiac rhythm management devices (CRMD), occurring in about 1%. While most lead perforations occur early, numerous instances of delayed lead perforation (occurring >30 days after implantation) have been reported in the last few years. Only about 40 such cases have been published, with the majority occurring <1 year after implantation. Herein, we describe the case of an 84-year-old female who presented with recurrent syncope and was diagnosed to have delayed pacemaker lead perforation 4.8 years after implantation. Through this report, we intend to highlight the increasing use of CRMD in elderly patients, and the lifelong risk of complications with these devices. Presentation can be atypical and a high index of suspicion is necessary for diagnosis.

No MeSH data available.


Related in: MedlinePlus