Pacemaker-dependent Patient Research Articles

T-wave oversensing and symptomatic bradycardia in a pacemaker-dependent heart failure patient due to drug-induced hyperkalemia

Hyperkalemia is a common clinical condition among heart failure patients especially if there is coexisting older age, potassium-sparing medication, and renal insufficiency. Close follow-up and titration of renin-angiotensin-aldosterone system inhibitors are essential to prevent the development of hyperkalemia. It can also cause significant abnormalities in patients with cardiac implantable electronic devices (CIED) including pacemakers and implantable cardioverter defibrillators (ICD) due to its impact on cardiac electrophysiology. Herein, we presented a pacemaker-dependent heart failure patient with single-chamber ICD in whom bradyarrhythmia signs and symptoms were observed due to T-wave oversensing and managed appropriately.

B-PO03-067 PACEMAKER EXIT-BLOCK AFTER RADIOABLATION FOR VT CAUSING INAPPROPRIATE ICD SHOCKS AND BRADYCARDIC ARREST

Stereotactic body radiation therapy (SBRT) is an emerging tool for the treatment of VT where catheter ablation has failed or is technically not feasible. Knowledge of the acute and chronic electrophysiologic sequelae, including changes in functioning of device therapy, is an evolving area. We report the first known case of inappropriate ICD shocks and severe bradycardia due to exit-block in a pacemaker dependent patient as a late-onset phenomenon following successful SBRT for VT. NA NA A 54-year-old female with a history of scar-related VT despite amiodarone therapy and chemical sympathectomy underwent successful SBRT for VT seven months prior. She was pacemaker dependent (CRT-D) with stable thresholds post-SBRT. She presented to hospital with multiple episodes of conscious ICD shocks due to R-wave double counting and misclassification as VF from interventricular conduction delay or RV loss of capture (LOC). At testing, LV and RV pacing thresholds were measured to be stable however. She later experienced severe bradycardic episodes due to intermittent LV and RV LOC that was stabilised by programming her CRT to maximum output. Definitive treatment was with insertion of a new transcutaneous RV lead and removal of LV lead. This is the first known case of delayed-onset exit-block occurring following SBRT for VT with sequelae of inappropriate ICD shocks and profound bradycardia due to dynamic conduction delay, variable pacing threshold and interplay with CRT programming. It is important that the electrophysiology team is aware of these issues.

Tachycardia in a pacemaker dependent patient: What went wrong?

A 67-year-old man presented to our emergency department complaining of palpitations, chest tightness, and shortness of breath. This article is protected by copyright. All rights reserved.

A pacemaker-dependent patient undergoing high-dose stereotactic radiotherapy with the device located in the radiation area.

A pacemaker-dependent patient undergoing high-dose stereotactic radiotherapy with the device located in the radiation area.

Treating or Killing? The Divergent Moral Implications of Cardiac Device Deactivation

In this article, I argue that there is a moral difference between deactivating an implantable cardioverter defibrillator (ICD) and turning off a cardiac pacemaker (CP). It is, at least in most cases, morally permissible to deactivate an ICD. It is not, at least in most cases, morally permissible to turn off a pacemaker in a fully or significantly pacemaker-dependent patient. After describing the relevant medical technologies-pacemakers and ICDs-I continue with contrasting perspectives on the issue of deactivation from practitioners involved with these devices: physicians, nurses, and allied professionals. Next, I offer a few possible analyses of the situation, relying on recent work in medical ethics. Considerations of intention, responsibility, and replacement support my distinguishing between ICDs and CPs. I conclude by recommending a change in policy of one of the leading cardiac societies.

DIFFICULT DIAGNOSIS OF SEPSIS ASSOCIATED WITH PACEMAKER LEAD INFECTION IN THE ELDERLY: THE ROLE OF POSITRON EMISSION TOMOGRAPHY

A case report of local infection along the pacemaker leads diagnosed as a cause of sepsis in an elderly pacemaker-dependent patient is described. Standard clinical and laboratory observation yielded no local infection responsible for sepsis. Additional evaluation using [18F]-fluorodesoxyglucose positron emission tomography was used for localization of occult infection. Complete pacemaker system deimplantation allowed successful treating of the patient.

Management of a leadless pacemaker recall via extraction in a patient with a history of multiple previous device implants

We describe a management strategy of a leadless pacemaker recall (LP) via extraction in a pacemaker-dependent patient with a history of multiple previous device implants. We performed a two-step procedure. First, we implanted a second LP in the right ventricle. Then, 3 days later for concerns about the stability of the newly-implanted device, we retrieved the first LP, 3 years after its original implant. The patient was hemodynamically stable throughout the two procedures and no adverse event occurred in the 3 days of coexistence of the two LPs. Although the limitation of a single case experience, this approach may be taken into consideration when facing similar high-risk cases.

Oversensing of the wearable cardioverter defibrillator during bipolar ventricular stimulation.

SummaryThe wearable cardioverter defibrillator (WCD) is a temporary treatment option for patients with potentially reversible risk of sudden cardiac death. This case demonstrates a pitfall during WCD usage in a pacemaker-dependent patient as well as a possible solution allowing continuation of WCD therapy. Bipolar stimulation may lead to double counting of the WCD detection algorithm resulting in false alarm or inappropriate therapy.

New alternative approach in case of pacemaker-dependent patient with bilateral pocket infection and persistent superior vena cava (or venous drainage abnormality)

This paper describes the case of pacemaker-depandent male patient with upper body venous dreinage anomaly, who suffered from bilateral pocket infection. This difficult situation made it impossible to implant the device in the subclavian region and forced us to search for an alternative access for right ventricular pacing. Presented case describes new possibilities in electrotherapy which are provided by technological development and miniaturization of medical devieces.

Fainting episode in a pacemaker dependent patient with two implanted devices. Too much of a good thing!

A 73 year old man with CRT-D system and pacemaker dependence was admitted to the emergency department due to a syncopal episode. The device interrogation was performed. An RV ventricular sensing test was executed in VVI mode at 50 b/m. During testing the patient developed transient loss of consciousness with full recovery after stopping the sensing test. Applying asynchronous pacing mode, a pacing spike occurred at a faster rate of 65 b/m without evoking any ventricular capture. Looking at the chest X-ray, we found an abandoned right sided, single chamber VVI pacemaker in a submuscular pocket. The CRT-D system was positioned on the left side. The abandoned pacemaker was in ERI and it switched to VVI 65 b/m resulting in inhibition CRTD device during sensing test. This troubleshooting highlights the possible interference between two devices.

Extraction of a trapped pacemaker lead in a pacemaker-dependent patient

A 47-year-old female with a dual chamber pacemaker was referred to our institution for transvenous lead removal because of suspected pocket infection.The history of this patient started in 2002 with a tricuspid valve endocarditis. Therefore, the patient had tricuspid valve repair that yielded a poor outcome.The patient received biological tricuspid valve in 2006. Due to postoperative total atrioventricular-block a DDDR device was implanted. The biological valve degenerated and thus was replaced by a mechanical one in 2014. During this valve implantation the atrial lead was removed and the ventricular lead was trapped by the mechanical valve between the native tricuspid valve annulus of the right ventricle and the outer ring of the mechanical valve. Three months after the last revision the patient developed signs of inflammation. The pocket was opened and a swab test proved positive for Staphylococcus epidermidis. After disinfection with iodine solution the pacemaker was placed under the pectoralis muscle. However, during the following 3 months the patient suffered from swelling over the pacemaker pocket and severe pain.In awareness of the previous history and the clinical symptoms we decided to implant a new pacemaker system on the left side and explant the infected system on the right side.<Learning objective: Pocket infections always require system explantation. Simultaneous explantation of an infected system and implantation of a new system within the same session is not recommended but was necessary in this case. Even complex lead extraction like this one can be successfully performed applying the appropriate tools (locking stylet, Evolution device, Cook Intravascular Inc., Leechburg, PA, USA).>

Sudden Death in Patients With Cardiac Implantable Electronic Devices.

Interrogations and autopsies of sudden deaths with cardiac implantable electronic devices (CIEDs) are rarely performed. Therefore, causes of sudden deaths with these devices and the incidence of device failure are unknown. To determine causes of death in individuals with CIEDs in a prospective autopsy study of all sudden deaths over 35 months as part of the San Francisco, California, Postmortem Systematic Investigation of Sudden Cardiac Death (POST SCD) study. Full autopsy, toxicology, histology, and device interrogation were performed on incident sudden cardiac deaths with pacemakers or implantable cardioverter defibrillators (ICDs). The setting was the Office of the Chief Medical Examiner, City and County of San Francisco. Participants included all sudden deaths captured through active surveillance of all deaths reported to the medical examiner and San Francisco residents with an ICD (January 1, 2011, to November 30, 2013). Identification of a device concern in sudden deaths with CIEDs, including hardware failures, device algorithm issues, device programming issues, and improper device selection. For the ICD population, outcomes were the cumulative incidence of death and sudden cardiac death and the proportion of deaths with an ICD concern. Twenty-two of 517 sudden deaths (4.3%) had CIEDs, and autopsy revealed a noncardiac cause of death in 6. Six of 14 pacemaker sudden deaths and 7 of 8 ICD sudden deaths died of ventricular tachycardia or ventricular fibrillation. Device concerns were identified in half (4 pacemakers and 7 ICDs), including 3 hardware failures contributing directly to death (1 rapid battery depletion with a sudden drop in pacing output and 2 lead fractures), 5 ICDs with ventricular fibrillation undersensing, 1 ICD with ventricular tachycardia missed due to programming, 1 improper device selection, and a pacemaker-dependent patient with pneumonia and concern about lead fracture. Of 712 San Francisco residents with an ICD during the study period, 109 died (15.3% cumulative 35-month incidence of death), and the 7 ICD concerns represent 6.4% of all ICD deaths. Systematic interrogation and autopsy of sudden deaths in one city identified concerns about CIED function that might otherwise not have been observed. Current passive surveillance efforts may underestimate device malfunction. These methods can provide unbiased data regarding causes of sudden death in individuals with CIEDs and improve surveillance for CIED problems.

Defibrillator Deactivation against a Patient's Wishes: Perspectives of Electrophysiology Practitioners.

Unilateral do-not-resuscitate (DNR) orders (against patient/family wishes) have been ethically justified in cases of medical futility. We investigated whether electrophysiology practitioners believe medical futility justifies unilateral implantable cardioverter defibrillator (ICD) deactivation. Email invitations to take an online survey were sent to 1,894 electrophysiology practitioners. A total of 384 responses were collected (response rate 20.6%). Though the sample included respondents from Europe, Asia, Australia, South America, and Africa, the majority were from North America (78%), were academically affiliated (64%), and practiced in an urban setting (67.8%). Deactivation of ICD shock function in agreement with patient wishes and a preexisting DNR were not considered physician-assisted suicide (93.2%, 358/384). However, a majority of the sample responded that it was not ethical/moral for doctors to deactivate ICDs against patients' wishes (77.1%, 296/384) or against family/surrogates' wishes (72.4%, 278/384), even in the context of medical futility. A majority indicated that deactivating ICD shock function is not ethically/morally different than withholding cardiopulmonary resuscitation or external defibrillation in a code (72.7%, 277/381), but was different than deactivating pacing in a pacemaker-dependent patient (82.8%, 318/384). In the classification of interventions, a plurality (43.0%, 165/383) regarded ICDs to be unlike any other intervention. Concerning pacemakers, 50% (191/382) considered them to be like dialysis (a therapy that keeps patients alive). This international sample of electrophysiology practitioners considered ICD and pacemaker deactivation to be ethically distinct. While ICD deactivation was considered appropriate in the setting of patient/family agreement, unilateral deactivation was not.

Navigating the 7 cs of certified practice.

Navigating the 7 cs of certified practice.

An Ethical Analysis of Withdrawal of Therapy in Patients with Implantable Cardiac Electronic Devices: Application of a Novel Decision Algorithm.

Patients with cardiovascular implantable electronic devices (CIEDs), which include pacemakers and implantable cardioverter-defibrillators (ICDs), may request deactivation of their devices as they approach the end of life. The Heart Rhythm Society (2010) has stated that "ethically, and legally, there are no differences between refusing CIED therapy and requesting withdrawal of CIED therapy." On the basis of the principle that there is no ethical distinction between withholding and withdrawing treatment, this professional organization has suggested that both the antibradycardia and antitachycardia features of these devices may be disabled at the patient's request. We argue that disabling ICD shocks is analogs to a do-not-resuscitate order and is ethically permissible whereas withdrawing pacing from a pacemaker-dependent patient is an act of intentionally hastening death and not morally licit.

How to temporarily pace a pacemaker-dependent patient after lead extraction for device infection?

We read with interest the work by Pecha et al .1 recently published in the Journal . The authors aimed to evaluate a new option of temporary pacing (TP) in pacemaker-(PM)-dependent patients undergoing lead extraction (LE) for a cardiac implantable electronic device (CIED) infection, that was used to delay re-implantation and improve safety and freedom from re-infection in follow-up. An active-fixation lead (AFL) was ipsilaterally implanted and connected to an externalized PM, in this way keeping the infected extraction side for TP and preserving the site of definitive device re-implantation. They did not observe infection recurrences, nor lead dislocation after a mean follow-up time of 21.1 months in spite of the long duration of TP (median 12.7 days, …

'Green light': watch it twice...

In Panel A you can see how the green rectangle and the ‘No Alert’ message (black arrows) of the welcoming screen are falsely reassuring in this completely pacemaker-dependent patient (red arrow) implanted with an Identity SR (St Jude Medical®) device. This is in disagreement with the announced tension value (2.66 V) and …

GW24-e0442 Inhibition of biventricular pacing due to oversensing of atrial fibrillation by a left ventricular lead: Interest of remote monitoring

ObjectivesAtrial oversensing by a ventricular lead may cause asystole in a pacemaker dependent patient or inappropriate shocks in an implanted cardioverter defibrillator recipient patient. In cardiac resynchronization therapy (CRT) devices...

Utility and safety of temporary pacing using active fixation leads and externalized re-usable permanent pacemakers after lead extraction

After extraction of an infected cardiac implantable electronic device (CIED) in a pacemaker-dependent patient, a temporary pacemaker wire may be required for long periods during antibiotic treatment. Loss of capture and under sensing are commonly observed over time with temporary pacemaker wires, and patient mobility is restricted. The use of an externalized permanent active-fixation pacemaker lead connected to a permanent pacemaker generator for temporary pacing may be beneficial because of improved lead stability, and greater patient mobility and comfort. The aim of this study was to investigate the efficacy and safety of a temporary permanent pacemaker (TPPM) system in patients undergoing transvenous lead extraction due to CIED infection. Of 47 patients who underwent lead extraction due to CIED infection over a 2-year period at our centre, 23 were pacemaker dependent and underwent TPPM implantation. A permanent pacemaker lead was implanted in the right ventricle via the internal jugular vein and connected to a TPPM generator, which was secured externally at the base of the neck. The TPPM was used for a mean of 19.4 ± 11.9 days (median 18 days, range 3-45 days), without loss of capture or sensing failure in any patient. Twelve of 23 patients were discharged home or to a nursing facility with the TPPM until completion of antibiotic treatment and re-implantation of a new permanent pacemaker. External TPPMs are safe and effective in patients requiring long-term pacing after infected CIED removal.

Enterococcus septicemia due to a pacemaker lead infection

Pacemaker lead infections are rare but potentially life threatening. We report the case of an 80-year-old pacemaker-dependent female patient with complete heart block, who presented with subfebrile temperatures and chills due to a pacemaker lead infection by Enterococcus faecalis.