Pacemaker Lead Research Articles

Characterization of tricuspid regurgitation in patients following left bundle branch pacing

Abstract Background Pacemakers placed in the right ventricle apex can lead to mechanical and electrical dyssynchrony. There is a growing interest in more physiologically stimulating techniques, and in this context, left bundle branch pacing (LBBP) emerges as an option. In this pacemaker, the lead is positioned perpendicular to the septum approximately 15-20 mm below the tricuspid valve annulus, and the helix is advanced towards the left side (Image 1). There is limited data on the incidence of new-onset tricuspid regurgitation (TR) or deterioration of pre-existing TR following the implantation of this type of pacemaker. Purpose To characterize the incidence of TR or deterioration of pre-existing TR after LBBP and to determine if there are predictors of a higher degree of TR. Methods All patients who received a pacemaker with LBBP between January and October 2023 were consecutively recruited. A transthoracic echocardiogram following the implantation of the pacemaker was performed to assess the size and function of right heart chambers, degree of TR and position of pacemaker lead. Continuous variables are expressed as mean ± SD or median [IQR] and categorical variables as absolute (%). Results There were 31 implants with a mean age of 73.4±8.7 years and 42% women. Nine patients (22.5%) had atrial fibrillation, and 7 patients (23%) had known coronary artery disease. The main indication for implant was a complete AV block (63.3%). Two patients had TR greater than moderate before the implantation of the pacemaker. Mean time elapsed between implantation and follow-up echocardiogram was 5.8 months. The distance between the lead-implanted site to the tricuspid annulus (Lead-TA distance) was 26.7±10.5 mm, mean lead depth in the interventricular septum (IVS) was 7.7±1.8mm and the IVS thickness at the lead-implanted site was 10.6±2.1 mm. Overall, TR worsed less than 1 degree after the lead implant (table 2) and was significantly related with the Lead-TA distance (TR worsed 0.3 degrees in Lead-TA distances shorter than 26.7mm and TR reduced 0.2 degrees in Lead-TA distances longer than 26.7mm, p=0.037). Conclusions In the short term following the implantation of an LBBP pacemaker the distance from the lead to the tricuspid annulus has an acute impact on tricuspid regurgitation, with TR worsening at short Lead-TA distances and TR improving at longer distances.

Pacemaker lead jailed by the TricValve system: first image report.

Pacemaker lead jailed by the TricValve system: first image report.

Echocardiographic predictors and associated outcomes of multiple vegetations in infective endocarditis: A pilot study.

Infective endocarditis (IE) is a life-threatening infection with an annual mortality of 40%. Embolic events reported in up to 80% of patients. Vegetations of > 10 mm size are associated with increased embolic events and poor prognosis. There is a paucity of literature on the association of multiple vegetations with outcome. To study the echocardiographic (ECHO) features and outcomes associated with the presence of multiple vegetations. In this retrospective, single-center, cohort study patients diagnosed with IE were recruited from June 2017 to June 2019. A total of 84 patients were diagnosed to have IE, of whom 67 with vegetation were identified. Baseline demographic, clinical, laboratory, and ECHO parameters were reviewed. Outcomes that were studied included recurrent admission, embolic phenomenon, and mortality. Twenty-three (34%) patients were noted to have multiple vegetations, 13 (56.5%) were male and 10 (43.5%) were female. The mean age of these patients was 50. Eight (35%) had a prior episode of IE. ECHO features of moderate to severe valvular regurgitation [odds ratio (OR) = 4], presence of pacemaker lead (OR = 4.8), impaired left ventricle (LV) relaxation (OR = 4), and elevated pulmonary artery systolic pressure (PASP) (OR = 2.2) are associated with higher odds of multiple vegetations. Of these moderate to severe valvular regurgitation (P = 0.028), pacemaker lead (P = 0.039) and impaired relaxation (P = 0.028) were statistically significant. These patients were noted to have an increased association of recurrent admissions (OR = 3.6), recurrent bacteremia (OR = 2.4), embolic phenomenon (OR = 2.5), intensive care unit stay (OR = 2.8), hypotension (OR = 2.1), surgical intervention (OR = 2.8) and device removal (OR = 4.8). Of this device removal (P = 0.039) and recurrent admissions (P = 0.017) were statistically significant. This study highlights the associations of ECHO predictors and outcomes in patients with IE having multiple vegetations. ECHO features of moderate to severe regurgitation, presence of pacemaker lead, impaired LV relaxation, and elevated PASP and outcomes including recurrent admissions and device removal were found to be associated with multiple vegetations.

Tricuspid Valve Repair With Preservation of Pacemaker Lead

Tricuspid Valve Repair With Preservation of Pacemaker Lead

Very early fractures of the stylet-driven Biotronik Solia lead used for left bundle branch area pacing

Abstract Introduction Left bundle branch area pacing (LBBAP) has become increasingly popular due to the relatively simple implantation procedure allowing for conduction system pacing (CSP). Initially, lumen-less leads have been used primarily for CSP. However, several authors have published encouraging results using conventional stylet-driven pacemaker (PM) leads as well and our centers have largely adopted this approach. Methods In our two tertiary referral centers, we assessed all patients, who underwent a LBBAP lead implantation using any lead. We observed several early lead fractures, exhibiting a unique failure mechanism, which we illustrate in this case-series. Results Between January 2022 and November 2023 343/393 patients (87.3%) were implanted with a Solia pacemaker lead, 46/393 (11.7%) received a SelectSecure 3830 lead, and 4/393 (1.0%) another stylet-driven lead. Three patients (0.8%) who initially were implanted with a Solia lead experienced very early intracardiac lead fractures within 1, 11 and 13 months after implantation despite good initial electrical performance values (Table shows initial values and values during the time of failure (bold)). The first case was a 54 year-old woman with permanent 3d degree AV block receiving an LBBAP lead after lead extraction. Four weeks later, she presented with presyncope and exit block at maximum output in uni- and bipolar configuration. The second case was a 72 year-old man with intermittent 3rd degree AV block in the context of an ischemic heart disease. He received a dual-chamber LBBAP PM. 13 months after the implantation, a bipolar impedance > 2’500Ω and exit block were noted. The third case was 65 year-old man suffering from sick sinus syndrome. He initially underwent a dual-chamber PM implantation in 2011 and due to ventricular sensing issues a transvenous lead extraction and implantation of a LBBAP lead in October 2022. During device follow-up after 11 months, a fractured LBBAP lead with bipolar impedance >2’500Ω and exit block during threshold testing was noticed. In all cases, X-rays and macroscopic analysis consistently showed a disintegration of the lead immediately distal to the ring electrode (Figure; site of fracture marked with an arrow). Most likely, this was caused by the repetitive shear stress at the hinge point of the lead where it is entering the septum. Conclusion No dedicated stylet-driven CSP lead is available to date. The implantation site and technique for LBBAP may exert higher mechanical stress on the distal part of the lead, making it more prone to fracture than in a conventional position. Currently, the use of conventional stylet-driven leads is still off-label and the performance of such leads should be monitored closely.TableFigure

Incidence and prognosis of subclinical cardiac perforation after leadless pacemaker implantation

Abstract Introduction Subclinical cardiac perforation, a known complication of cardiac implantable electronic device leads, occurs in 6–20% of cases. While leadless pacemakers are advised to be placed in the septum to mitigate perforation risk, limited studies exist on lead positioning and perforation incidence. Objectives This retrospective observational study aimed to assess leadless pacemaker lead positions, determine the incidence of subclinical cardiac perforation, and evaluate associated prognoses through computed tomography (CT) in post-implantation patients. Methods Thirty-one patients underwent CT after leadless pacemaker implantation. Two cardiologists and a radiologist analyzed CT scans to categorize lead positions (septum, free wall, or septum-free wall junction) and identify subclinical perforation (defined as tine transversal beyond the outer myocardial contour without symptoms, hemodynamic instability, or pacemaker issues). Results Mean age at implantation was 70.5 ± 12.7 years; 35.5% were male, and 41.9% had atrial fibrillation. Twenty patients (64.5%) were on anticoagulants or antiplatelet agents. Twenty-four patients (77.4%) were positioned at the septum-free wall junction. Subclinical perforation occurred in 12 patients (38.7%), with a higher proportion in patients on non-vitamin K antagonist oral anticoagulants. Two patients had moderate amount of pericardial effusion; the remaining ten with subclinical perforation were stable during follow-up. Conclusions The most common leadless pacemaker implantation site was the septum-free wall junction with 38.7% of subclinical perforation.

Pacemaker lead is observable in the RVOT. Pacemaker lead oscillates in the RVOT as the heart beats. Moderate to large PE was seen in the pericardial cavity.

Pacemaker lead is observable in the RVOT. Pacemaker lead oscillates in the RVOT as the heart beats. Moderate to large PE was seen in the pericardial cavity.

Pacemaker lead has penetrated the myocardium into the pericardial cavity. Pacemaker lead oscillates in the pericardial cavity as the heart beats. Moderate to large PE was seen in the pericardial cavity.

Pacemaker lead has penetrated the myocardium into the pericardial cavity. Pacemaker lead oscillates in the pericardial cavity as the heart beats. Moderate to large PE was seen in the pericardial cavity.

Perforation of Left Ventricular wall and Ipsilateral Pleura by a Right Ventricular Pacemaker lead: Case Report

Introduction: Malposition of pacemaker lead is uncommon event and it usually regard the right ventricle. In rare cases, the perforation can involve the left ventricle and this is a potentially life-threatening complication. Case presentation: We described a case of both septum and LV free wall perforation by an RV pacemaker lead in an 84-year-old woman. Perforation also resulted in left pneumothorax and she became symptomatic. She also had pericardial effusion, so she underwent cardiac surgery to repair the bleeding lesion. As the swab for Covid-Sars 2 was positive, we had to wait for the negativization for the replacement of the ventricular lead. Conclusions: early identification is mandatory to prevent this complication and transvenous lead extraction with cardiac surgery backup should be considered.

Late Unexpected Pneumopericardium Due to Pleuro-pericardial Atrial Perforation by Pacemaker Lead

Late Unexpected Pneumopericardium Due to Pleuro-pericardial Atrial Perforation by Pacemaker Lead

Pacemaker lead dislocation during TricValve procedure with an extremely small superior vena cava

Pacemaker lead dislocation during TricValve procedure with an extremely small superior vena cava

Cardiovascular images: pacemaker-lead fracture and excessive coiling in a dog

A seven-year-old male castrated Labrador Retriever presented emergently due to concern for pacemaker malfunction five years after successful transvenous pacemaker implantation to treat partial atrial standstill. On presentation, the dog's pulse rate was 30–50 beats per minute. An electrocardiogram showed no spontaneous atrial activity or paced ventricular activity. Pacemaker interrogation revealed an increased impedance of 7557 ohms, indicating a lead malfunction. Thoracic radiographs confirmed the lead was fractured and had excessive coiling. The transvenous pacing system was turned off, left in place, and an epicardial pacing system was implanted the following day. The dog was discharged with no perioperative complications. The dog eventually required escalated medical therapy for progressive cardiac disease and was euthanized two years after implantation of the replacement pacemaker. This manuscript illustrates a complete lead fracture and excessive lead coiling, which has not previously been detailed in veterinary medicine.

Cardiac computed tomography findings in a rare case of cardiac perforation due to pacemaker lead

Cardiac computed tomography findings in a rare case of cardiac perforation due to pacemaker lead

Acousto-optic-based time domain electric field sensor for magnetic resonance imaging applications.

An acousto-optic (AO)-based electric field sensor is presented for time domain measurement under magnetic resonance imaging (MRI). A fully MR-compatible sensor is designed and fabricated using a phase-shifted fiber Bragg grating mechanically coupled to a piezoelectric transducer. Mechanical resonance of the piezoelectric transducer is matched to the operating frequencies of commonly used MRI systems to increase the sensitivity of the sensor. Sensitivity of the sensor is measured as 1.27 mV/V/m, with a minimum detectable electric field of 4.4 mV/m/√/Hz. Directivity of the sensor is measured with a 18 dB orthogonal component rejection. The dynamic range of the sensor is calculated as 117 dB/Hz, which allows the measurement of electric fields up to 3.2 kV/m. In MRI studies, the AO sensor was able detect local hot spots around a reference implant accurately with high signal-to-noise ratio. AO sensor exhibited similar or better performance when compared with commercially available MRI compatible electric field sensors. Furthermore, the small size of the sensor with the flexible fiber optic link could allow in situ measurements of electric fields during critical interventional procedures such as pacemaker lead or deep brain stimulator placement as an MRI dosimeter during diagnostic scans.

A Very Rare Case of Primary Mural Endocarditis of the Right Atrium due to Candida Albicans

Right-sided infective endocarditis accounts for 5-10% of all infective endocarditis cases. Fungal endocarditis represents 1-3% of all of infective endocarditis cases, with Candida spp. being the most common microbiological cause. Primary mural endocarditis is defined by the absence of valvular vegetations together with the presence of vegetations on the endocardial free wall that are not associated with myocardial abscesses, cardiac structural abnormalities, devices, prosthetic material, thrombi or tumors. It constitutes a very rare entity and only 63 cases have been published the literature. C. albicans is the microbiological cause in only nine of these cases, none of which involves the right atrium. We report the case of a frail 84-year-old female patient with a pacemaker presenting with fever. In the transthoracic and three-dimensional transesophageal echocardiograms, a mobile mass was found attached on the free wall of the right atrial base. Blood cultures were positive for C. albicans and the modified Duke criteria were fulfilled for a definite diagnosis of infective endocarditis. After evaluation from a heart team the patient was managed with transvenous lead extraction and intravenous high-dose caspofungin, according to the 2023 Guidelines of the European Society of Cardiology for the management of endocarditis. Pacemaker lead cultures were negative leading to the diagnosis of primary mural endocarditis. The patient responded well to treatment with significant clinical and laboratory improvement. Long-term oral fluconazole was initiated after hospital discharge with a close follow-up plan. To our knowledge this is the first case of primary mural endocarditis of the right atrium due to C. albicans.

Challenges in Retrieving a Knotted Temporary Pacemaker Lead: Lessons Learned from a Case Study.

Challenges in Retrieving a Knotted Temporary Pacemaker Lead: Lessons Learned from a Case Study.

Subacute right ventricular perforation from a passive fixation pacemaker lead - a multidisciplinary diagnostic and management work-up

Cardiac implantable electronic devices (CIEDs) implantation procedure has a complication rate of 5-6% according to most studies. Lead perforation is a possible and serious adverse event which can present with a spectrum of symptoms from asymptomatic to sudden death. Diagnostic tools in case of suspected lead perforation are X-ray, transthoracic echocardiography, pacemaker interrogation and computed tomography with the last one being the gold standard. Lead extraction could be done endovascularly or surgically. Transvenous removal is a possible option for active fi xation leads, while removal of passive fi xation leads is preferably done surgically, because of the bulky tip of the lead, which could damage the heart chambers and the vessels. In this article, we present a case of a massive ventricular perforation from a passive fi xation lead, further complicated by a cardiac tamponade. Surgical removal was the treatment of choice with subsequent implantation of a permanent dual-chamber pacemaker. 

A Heart-Stopping Tale of a Simple Arm Movement. A Tragic Consequence of a Fractured Pacemaker Lead

A Heart-Stopping Tale of a Simple Arm Movement. A Tragic Consequence of a Fractured Pacemaker Lead

Case of a misleading ECG

An elderly man with severe chronic obstructive pulmonary disease and a history of complete heart block with pacemaker placement was found to have pacemaker lead infection and required device extraction. He had a standard dual chamber pacemaker in place, however the ECG obtained showed paced QRS complexes with presence of R wave in lead V1 and QS in lead I suggestive of left ventricular pacing. Additional imaging with CT scan obtained for confirmation revealed that the heart was displaced to the left posterior hemithorax secondary to pulmonary disease. Due to significant posterolateral rotation of the heart, a right ventricular paced rhythm can demonstrate Q/S waves in the lateral leads (I, aVL, V5–6) and R waves in the right precordial leads (V1–3). This can be misdiagnosed as a left ventricular paced rhythm.

Motion Characterization of Pacemaker Lead Wire In Vivo for Piezoelectric Energy Harvesting Applications.

Piezoelectric energy harvesters (PEH) for cardiac pacemakers typically use animal models to assess the performance of the PEH. However, if considering multiple designs, the use of animal models and prototyping increases costs and time. To reduce the use of animal models in research for pacemaker energy harvesting applications, this study investigates the motion of a pacemaker lead wire (PLW) in vivo using fluoroscopy imaging to quantify the position and displacements as a function of time, such that the data can be used in computer simulations. The proposed technique uses fluoroscopy imaging video data of a dual chamber pacemaker implanted in a patient, and image processing allows for the motion of the PLW captured. The motion is discretized into nodes for ease of implementation in finite element software. FEA simulation is presented using a piezoelectric energy harvester design integrated in the lead wire, and the energy output is predicted by finite element computer simulation. A 2-dimensional analysis is conducted with the fluoroscopy imaging video data to characterize the PLW motion and results show close agreement with literature values. Simulations with an energy harvesting circuit using the nodal position and displacement data shows that a PEH integrated in the PLW can generate a direct current voltage of 1.12V and power output of 0.125μW, potentially extending the battery life of pacemakers by 0.75-1years. The results suggest that fluoroscopy imaging data can be effective in evaluating PEH designs rather than using animal models, saving time and costs.