Complication Of Pacemaker Implantation Research Articles

434 TAKOTSUBO SYNDROME AFTER PACEMAKER IMPLANTATION

Abstract Introduction Takotsubo syndrome is a clinical syndrome characterized by typical anamnestic features together with typical ECG and echocardiographic findings. Comparing with the available literature not so many cases of takotsubo syndrome after pacemaker implantation can be found. Furthermore, there are only few articles talking about ECG features in these patient. The case we described allows to observe dynamic ECG alterations in a patient with electro-induced ventriculograms Case Description A 90-year-old male was admitted to the emergency room for important fatigue associated with severe bradycardia (25/min). His cardiovascular history was silent, and his past medical history was characterized by high blood pressure, chronic pulmonary obstructive disease and anemia due to iron deficiency. The ECG showed second degree AVB type 2, with phases of 2:1 AVB and paroxysmal third degree AVB on continuous monitoring. The routine blood tests showed normal T troponin and BNP was 420 pg/mL. The echocardiogram revealed normal biventricular dimensions and systolic function with moderate aortic valve stenosis. The patient underwent urgent permanent DDD pacemaker implantation without previous isoproterenol administration. During the procedure he referred important pain on the site of the wound, and he became confused and agitated. The procedure was complicated by massive pneumothorax that needed quick decompression. On the 2nd day after pacemaker implantation the ECG revealed electro-induced atrium-guided ventriculograms and began to modify with only mild ST-segment elevation in V2 and initial T-wave inversion from V3 to V6 and in I - II - aVF. On the next days, T-waves became deeper and QTc prolonged to 540 ms. These abnormalities were then gradually resolved on the 11th day. Mild transient attenuation of the amplitude of the QRS complexes in V2 – V3 leads on day 1 could be reported. Another echocardiogram was then performed, which showed new apical akinesis with “apical ballooning” aspect and EF of 40%. TnT and BNP values increased. Coronary angiogram was not performed due to patient rejection, so that coronaropathy could not be excluded with certainty. Nevertheless, the patient had only high blood pressure as cardiovascular risk factor and that the probability of the diagnosis of takotsubo cardiomyopathy was assessed of 76,9% by InterTAK diagnostic score, so that we considered Takotsubo syndrome the most likely diagnosis. Therefore, the patient's therapy was then optimized with an increase in the dosage of ACE inhibitors. At one month follow-up the ECG remained stable, and the echocardiogram showed a preserved ejection fraction (EF = 55%), without alterations of the segmental contractility. BNP and TnT values were normal. Therapy was left unmodified. Conclusions Takotsubo syndrome should be consider a rare but possible complication of pacemaker implantation. This is true especially for patients affected by frailty and cognitive impairment. There are no specific ECG criteria for takotsubo syndrome in patients with electro-induced ventriculograms, but anomalies of the repolarization are similar to those in patients with spontaneous ventricular activity. Transient attenuation of the QRS complexes voltages could be seen even just in the precordial leads and it is generally present in the very acute phase.

Patients Characteristic, Indications, and Complications of Permanent Pacemaker Implantation

Background: Permanent pacemaker implantation is a relatively safe procedure that significantly improves morbidity and mortality among patients with bradyarrhythmias. This study was conducted to determine the patients’ characteristics, indications, and complications of pacemaker implantation. Materials and Methods: This was a single-center, prospective study conducted in Azadi Heart Center, Duhok, Iraq between March 2013 and March 2020. All patients who had indications for permanent pacemaker implantation according to the current guidelines (AHA/ACC) were included and followed up for at least 1 year. Results: The study included 396 patients (242 males [61%] and 154 females [39%]) with a mean age of 65 ± 16 years. The most common presenting symptom was dizziness (63%). Atrioventricular block was the most common indication for pacing in 249 cases (63%), followed by sick sinus syndrome (SSS) in 138 patients (34.8%). The most common mode of pacing was DDD in 234 patients (59%). Among all patients undergoing permanent pacemaker implantation, 17 patients (4.25%) developed early and late complications. The most common early complication was pocket hematoma seen in four patients (1%), followed by pneumothorax in three patients (0.75%). Among late complications, painful shoulder was the most common affecting four patients (1%). Conclusions: Pacemaker implantation is a relatively safe procedure with a low complication rate. Elderly males were the most common group receiving permanent pacemaker. Dual-chamber (DDD) pacing mode was the most commonly used mode.

Frailty and cognitive impairment are predictive of takotsubo syndrome following pacemaker implantation.

Pacemaker (PM) implantation may cause acute emotional distress leading to takotsubo syndrome (TTS). Frailty and cognitive impairment are known to influence outcomes after surgical procedures. It is unclear whether they may also predispose to TTS following PM implantation. We identified nine cases (81 ± 6 years) of TTS following PM implantation that took place between 2013 and 2017 in one high volume implantation center. TTS was diagnosed based on typical echocardiographic appearance with resolution over time and (in cases where deemed necessary) normal coronary angiography. The TTS cases were compared with 30 consecutive cases of PM implantation (75 ± 9 years), which were not complicated by TTS (control group). Frailty was assessed using retrospective Risk Analysis Index (RAI-A). Pacing parameters were analyzed during PM implantation and after 1 month. Cognitive impairment was more prevalent (67%vs 10%, P=.0005), and RAI-A index was significantly higher in the TTS group compared to the control group (26 ± 13.7vs 13.1 ± 9.8, P=.008). Perioperative right ventricular threshold was significantly higher in patients with TTS comparing to controls (0.99 ± 0.43 V vs 0.74 ± 0.20 V, P=.04). The magnitude of decrease in right ventricular threshold between implantation and 1 month follow-up was greater in TTS patients compared to controls (-0.41 ± 0.29 V vs -0.15 ± 0.38 V, P=.049). TTS is a rare complication of PM implantation. Patients with cognitive impairment and frailty are at risk of TTS. Right ventricular pacing threshold is acutely affected by TTS and improves over time.

TAKOTSUBO, CORONARY ARTERY DISEASE, AND PACEMAKER: A CASE THAT STRINGS THE DOTS

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: TCM is a distinctive syndrome of reversible left ventricular systolic dysfunction, usually precipitated by an acute emotional or physiologic stress in two third of the cases. Commons symptoms include chest pain, dyspnea and palpitations which resembles acute coronary syndrome. We present a unique case in which TCM was induced by pacemaker placement that has been rarely reported. CASE PRESENTATION: We present a 75-year-old female without significant cardiac history presented with progressive lethargy and confusion. She was seen by her PCP prior to admission and was found to be in a sustained bradycardic status. Complete AV block with escape rhythm at 30 BPM was found on initial EKG. PPM was placed without immediate complication. However, she developed dyspnea at rest the subsequent day. She was found to be in acute heart failure with a modest increase of troponin (2.12). Repeat EKG showed normal paced rhythm and rate and without ischemic changes. Her TTE 6 months prior to admission displayed normal L/R ventricular function with normal EF. A repeat echo was performed which displayed "Apical ballooning” of the left ventricle with severe reduction of EF (15%). The findings were suggestive of TCM. The patient was started on aggressive diuresis regimen and therapeutic anticoagulation was also initiated. A cardiac angiogram was performed 2 days after which found significant single vessel disease was found in the LCX with an occluded ostial-proximal with faint left to left collaterals in a right dominance system. Medical management of CAD and TCM were given and the patient responded well to therapy. Follow up echocardiogram 2 months after the presentation showed reversed EF of 55% with normal regional wall motions. DISCUSSION: The definite diagnosis for TCM has always been rather ambiguous due to the novelty of this disease. The widely accepted diagnostic criteria have been the Mayo Clinic criteria which have been excluding patients that have CAD. However, around 15.3 % of the patient that had typical signs of TCM had CAD history. It is included in the European guideline that if the degree of regional wall function abnormality cannot be explained by the extent of CAD, TCM should be considered. As such, in our patient, who has a reversed cardiac function on the repeat TTE, had evidence that was suggestive of TCM. Although we did not perform an echocardiogram prior to the procedure, the patient at that time did not exhibit signs of heart failure nor having signs of ACS. She subsequently developed clinical symptoms of heart failure soon after the procedure that was confirmed with TTE. It is quite apparent that the PPM procedure was the sole stress factor. CONCLUSIONS: Patients that have findings that support TCM with CAD should not be excluded out from the diagnosis of TCM. Clinicians should be aware that TCM may be a complication after PCM placement. Reference #1: Takotsubo cardiomyopathy: A potentially serious trap (Data from the International Takotsubo Cardiomyopathy Registry); Glob Cardiol Sci Pract. 2015; 2015(4): 55. Reference #2: Takotsubo cardiomyopathy as a complication of pacemaker implantation; Journal of Cardiovascular Medicine: October 2011 - Volume 12 - Issue 10 - p 754–760 https://doi.org/10.2459/JCM.0b013e3283403563 DISCLOSURES: No relevant relationships by Chien-Ting Kao, source=Web Response No relevant relationships by Amr Salama, source=Web Response

RF78 SUCCESFULL MANAGMENT OF PACEMAKER POCKET INFECTION IN A NEONATE COMBINING VACUUM-ASSISTED THERAPY WITH PLASTIC SURGERY WITHOUT DEVICE REMOVAL

Background: Infection is a serious complication of pacemaker implantation,even more in neonates. Optimal treatment of infections related to pacemaker is poorly defined. We describe a succesfull pacemaker's pocket infection treatment,without device removal, in a neonate. Methods: In October 2017 a 2 weeks old,2,5 kg neonate,underwent epicardial double chamber pacemaker implantation for a congenital complete atrio-ventricular block. Via median sternotomy 2 bipolar steroid eluting leads were sutured to the right atrium and right ventricular surfaces. The generator was placed in a subrectal pocket at midepigastric level. After 6 days skin dehiscence with purulent collection presented. From the pocket were isolated Enterobacter cloacae & S. Aureus. Amikacin and Meropenem were started as well as Vacuum-Assisted Therapy (VAC-T). The VAC dressing was changed every 4 days. Until demonstrated absence of infection (after 40 days treatment) we were confident with the chanche to avoid generator's removal. After 50 days of treatment,because of the big dimension of the bicameral generator we were not keen on resuture the pocket and we asked for a plastic surgery advise. The plastic surgeon performed a skin transfer flap from the right flank region. Results: The baby was discharged after 2 weeks from the pocket closure with no sign of inflammation nor skin erosion. After 6 months follow up the pocket is free of infection. Conclusions: To our knowledge this is the first description of succesfull treatment of a pacemaker pocket infection in a neonate,by means of VAC-T & a skin transfer without device removal.

Pacemaker-associated thrombosis in ongoing therapy with edoxaban tosylate

Thromboembolism is a known complication of pacemaker implantation. However, published literature describes only a few cases, in which the events occurred in absence of antithrombotic prophylaxis, not routinely employed for its prevention in current clinical practice. We report a case of pacemaker lead-associated thrombosis in a patient taking continuative oral anticoagulant therapy with edoxaban tosylate (edoxaban). No data in present literature supports the use of anticoagulant prophylaxis for pacemaker lead thrombosis. In our report ongoing treatment with edoxaban proved ineffective for thrombosis prevention. We also discuss the role of three-dimensional transthoracic echocardiography for diagnostic assessment of thrombosis in a fragile patient.

An incidental diagnosis of multiple pacemaker lead fractures

Lead fractures are uncommon complications of pacemaker implantation. This article describes a patient with an incidental diagnosis of multiple atrial lead fractures many years after pacemaker implantation.

Treatment of permanent pacemaker electrode-induced cardiac perforation

A case of permanent pacemaker electrode-induced perforation in the Third Affiliated Hospital of Inner Mongolia Medical University was collected and analyzed on the basis of diagnosis, physical examination and treatment. Cardiac perforation is one of the most serious complications of pacemaker implantation. As this disease is rare, it is easy to be misdiagnosed or missed diagnosis. We hope to improve the clinician’s awareness and vigilance of permanent pacemaker electrode perforation by analyzing the data of this case.

Three-dimensional transoesophageal echocardiography as the ultimate diagnostic tool in a case of unintentional left ventricular pacing

Unintentional lead placement in the left ventricle (LV) is a rare complication of pacemaker implantation. Despite the fact that these procedures are routinely guided by electrocardiography and fluoroscopic imaging, these monitoring methods may occasionally prove to be insufficient. These are the cases when echocardiography, especially three-dimensional (3D) echocardiography, may be of help. An 83-year-old male was admitted to our clinic due to suspected ventricular lead dislocation into the LV, detected in a routine follow-up chest X-ray film. Five years earlier, the patient underwent implantation of a Victory DR (DDDR) cardiac pacing system (from St. Jude Medical) with screw-in leads (atrial Optisense 52 and ventricular Optisense 58) due to complete atrioventricular block. The pacing parameters were good both initially and at the interim follow-up outpatient interrogations. A 12-lead electrocardiogram (ECG) tracing showed normal cardiac pacing in the DDDR mode with pacemaker-generated ventricular complexes of right bundle branch block (RBBB) morphology (Fig. 1A). Lateral-view fluoroscopy revealed the electrode forming a backward-facing arch (Fig. 1C, arrow), which is consistent with the ventricular lead passing from the right atrium (RA) through the foramen ovale into the LV. A detailed, three-dimensional (3D) course of both leads was visualised via 3D echocardiography. During lead insertion the ventricular lead was deflected by an abnormally large muscle rim in the RA, which altered its course (Fig. 2A). The lead passed from the RA through the anterior edge of the foramen ovale, and into the left atrium (LA) (Fig. 2B). Finally, the lead passed through the mitral valve at the border of segments P2 and P3 into the LV (Fig. 3A), where its tip eventually rested in the basal part of the lateral apical segment of the LV (Fig. 3B). Right endocavitary pacing produces electrocardiographic evidence of left bundle branch block (LBBB). However, RBBB can also be seen in 8.3% of ECG tracings, a proportion that can be reduced to 4.3% by tracing modification with the Klein’s manoeuvre (lowering precordial leads by one intercostal space). Radiographic anterior-posterior images do not always show lead placement accurately and may fail to visualise complications of permanent pacing. In the case presented here, the suspected complication was confirmed echocardiographically. The 3D mode allowed an accurate visualisation of lead placement in the LV and helped explain the likely cause of lead misdirection. Figure 2. A, B. Three-dimensional transoesophageal echocardiography — two views from the middle oesophagus, modified. The lead passes through interatrial septum (IAS) in the anterior part of the foramen ovale; LA — left atrium; LV — left ventricle; RA — right atrium; TV — tricuspid valve

Clinical profiles and outcomes of patients undergoing pacemaker implantation

Background: The insertion of a permanent cardiac pacemaker is today one of the most commonly performed interventions on the heart. Various hypotheses have been put forward to explain the high incidence of conduction system disorders in the eastern part of our country. We studied the clinical profiles and outcomes of patients undergoing pacemaker implantation at the Regional Institute of Medical Science Imphal, Manipur, India. Materials and Methods: Thirty-seven patients who satisfied the inclusion criteria and underwent pacemaker implantation were studied. Detailed evaluation was done for each patient. Electrocardiography (ECG), echocardiography, chest x-ray, lipid profile, and other routine investigations were carried out. Patients were followed up for 6 weeks for any acute complication of pacemaker implantation. Results: Of the 37 patients, 21 (57%) were male, and the mean age of the study group was 63.24 years. The indications for pacemaker implantation were atrioventricular (AV) block [in 24 (64.9%) patients], sick sinus syndrome (SSS) [10 (27.1%)], and trifascicular block [3 (4.5%)]. The most common presenting symptoms were syncope (in 59.9% of patients), lightheadedness (62.2%), palpitation (56.7%), and dyspnea (56.7%). Cardic arrhythmias were associated with hypertension (in 59.5% of patients), diabetes mellitus (21.6%), thyroid disease (16.2%), and coronary heart disease (CAD,13.5%). In 32.4% of the patients there were associated comorbid conditions. No further syncopal attack occurred following pacemaker implantation, and the other symptoms improved significantly. The complications observed were pneumothorax and pacemaker implant site wound exudation in one patient each. Conclusion: The major indications of pacemaker implantation were found to be complete heart block (CHB) and SSS. Pacemaker implantation is a lifesaving procedure and improves quality of life dramatically. Complications associated with pacemaker implantation are relatively low.

Anaesthetic management and complications of pacemaker implantation in dogs

The aim of this study was to report the anaesthetic management and peri-anaesthetic complications of 57 dogs undergoing pacemaker implantation at a referral institution over 10 years (2002–2012). The median...

Pneumopericardium: an uncommon complication of atrial lead perforation following pacemaker implantation

Cardiac perforation is an infrequent but potentially life-threatening complication of pacemaker implantation. We report a case of right atrial lead perforation complicated by pneumopericardium shortly after pacemaker lead insertion. Transthoracic echocardiography revealed no evidence of pericardial effusion and pacemaker lead displacement, but a thoracic computed tomography scan illustrated the lead course and confirmed the diagnosis. This case suggests that computed tomography is a sensitive modality to confirm the diagnosis at the early stage of this complication.

Lead perforation: An uncommon cause of chest pain in a patient with pacemaker

Fig. 1. Pacemaker wire in the right ventricle close to the apex, also note moderate sized pericardial effusion. We thank Chen et al. [1] for their article regarding right ventricular septal perforation from an active fixation lead. This was very interesting, as usual for International Journal of Cardiology. We also recently had a 56-year-oldmalewhopresented to our emergency department with a 30-minute history of midsternal, stabbing chest pain. He underwent permanent pacemaker insertion 2 days prior to this presentation for third degree heart block. His vital signs and physical examination were unremarkable. His chest X-ray showed stable cardiomegaly without any pulmonary pathology. Electrocardiography revealed old left bundle branch block with a paced rhythm. Bedside transthoracic echocardiography was urgently obtained, revealing a moderate sized circumferential pericardial effusion and displacement of right ventricular (RV) pacer lead perforating through the apex (Figs. 1 and 2). The patient underwent emergent cardiac surgery which revealed 250 ml of blood in the pericardial space. His pacemaker wire was pulled back. The patient had an uncomplicated post-op course and was discharged to home in a stable condition. Lead perforation is an infrequent but potentially fatal complication of pacemaker implantation with published rate of 0.1–0.8% [2,3]. Patients with this complication typically present with recurring, stabbing chest pain and usually present within 1 month after implantation [3,4]. Transthoracic echocardiography is the initial diagnostic test of choice as it usually provides a clear visualization of the position of the lead tip as well as associated pericardial effusion. Chest computed tomography scan can be used if the initial echocardiography is not diagnostic [5]. Management of lead perforation depends on the patient's hemodynamic status. In a patient with hemodynamic instability or with rapid progression of pericardial effusion, surgical repair is generally mandated while simple direct traction with close echocardiographic

Left Hemothorax : An Unusual Complication of Delayed Right Ventricular Perforation by a Permanent Pacemaker Lead

Cardiac ventricle perforation by a pacemaker (PM) lead is an uncommon complication of PM implantation. We report a patient with a delayed right ventricular perforation from a permanent PM lead which presented as a left hemothorax.

Pacemaker implantation complication rates in elderly and young patients

AimsTo evaluate the complication rate differences between elderly and younger patients who receive a permanent pacemaker implantation.MethodsWe reviewed all cases admitted to our institution between January 2008 and June 2009 with symptomatic bradyarrhythmia for whom a permanent pacemaker was implanted. Beginning in June 2009, we prospectively collected data from all patients with the same diagnosis and procedure. The frequency of complications due to the pacemaker implantation procedure was evaluated and compared between young (<70 years old) and elderly (≥70 years old) patients.ResultsAmong 574 patients with a permanent pacemaker, 259 patients (45.1%) were below and 315 patients (54.9%) were above or at 70 years of age. There were 240 (92.7%) and 19 (7.3%) dual-chamber pacemaker (DDD) and single-chamber pacemaker (VVI) implanted patients in the younger group, and 291 (76.8%) and 73 (23.2%) DDD and VVI pacemaker implanted patients in the elderly group, respectively. The complication rate was 39 (15.1%) out of 259 young patients and 24 (7.6%) out of 315 elderly patients. Postprocedural complications were statistically lower in the elderly patients than in younger patients (P = 0.005).ConclusionA pacemaker implantation performed by an experienced operator is a safe procedure for patients of advanced age. The patients who are above 70 years old may have less complication rates than the younger patients.

Severe tricuspid regurgitation secondary to dislodgement of the atrial loop into the right ventricle: an unusual complication of pacemaker implantation in a young adult

Summary Transvenous pacemaker leads may impair tricuspid valve function. Severe tricuspid regurgitation due to leafl et adhesion to the pacemaker lead has not been reported in a young adult patient in the literature. Our patient underwent a transvenous pacemaker implantation for symptoms of bradycardia. An atrial loop was created in the right atrium for future growth. After 10 years of follow-up, the patient was seen with severe tricuspid regurgitation and enlarged right heart structures due to migration of the atrial loop of the pacemaker lead into the right ventricle and adhesion of the lead to the tricuspid valve. Cardiac surgery and epicardial pacing was the chosen procedure to solve this problem. The venous system and right heart valves should be carefully observed during the follow-up of children who underwent transvenous pacing.

Haemoptysis as a complication of pacemaker implantation

A 76-year-old man presented with haemoptysis that developed 7 days after dual-chamber pacemaker implantation at another hospital. The …

Takotsubo cardiomyopathy as a complication of pacemaker implantation

To the editorTakotsubo cardiomyopathy (TCM), first described by Japanese physicians in the 1990s,1 normally occurs following stressful situations or events.2,3 Although the specific cause of TCM is still debated, several factors have been proposed, such as coronary artery spasm,4 microvascular invol

Vacuum-Assisted Wound Closure for Pacemaker Infection

Although infection is a serious complication of pacemaker implantation, optimal treatment of infections related to pacemaker systems is poorly defined. We describe a man in his 60s, an octogenarian, and two nonagenarian females who were treated for an infected permanent pacemaker. All of these patients developed inflammation that presented as local symptoms and purulent collection in the pockets of their implanted pacemakers. After fenestration of the pacemaker pockets, they were treated with vacuum-assisted wound closure (VAC). Infection was eradicated in all the patients without the need for aggressive surgery. The open wound was re-sutured without complete removal of the pacemaker system in two patients. After removing the infected generator from the other two patients, the open wounds healed with or without re-suture. The mean duration of VAC was 19.5 days. The postoperative course of all of the patients was uneventful, and they remained completely asymptomatic after VAC, with no evidence of recurrent infection for 5- 15 months after discharge. When the risk of total system explantation is high, less-invasive VAC might serve as the option for treating an infected pacemaker. (PACE 2010; 426-430).

Cyanosis Produced By Superior Vena Caval Stenosis

Superior vena cava syndrome is a rare complication of pacemaker implantation. Narrowing and occlusion of the superior vena cava is often asymptomatic due to the formation of decompressive collateral pathways to the right atrium. We present a case in which an anomalous venous pathway allowed decompression of the systemic venous return into the left atrium, resulting in arterial desaturation, cyanosis, and fatigue.