Late perforation of a passively fixated pacemaker lead through the right ventricle. A report and review of literature

Abstract

Lead perforation is one of the serious complications associated with cardiac pacemakers and implantable cardiac defibrillators. Late perforations – occurring more than one month after placement – are exceedingly rare and are usually more associated with actively fixed leads rather than passively fixed tined leads. We present a case of blunt ended tined lead perforation after 4 months of implantation managed by a two-step hybrid minimally invasive approach consisting of mini-thoracotomy and lead tip transection, followed by trans-venous lead extraction.

<Learning objective: Late perforation of a pacemaker lead (occurring more than one month after placement) is an exceedingly rare complication and is usually more associated with actively fixed leads rather than passively fixed tined leads. We describe management of a blunt-ended tined lead perforation by a two-step hybrid minimally invasive approach consisting of mini-thoracotomy and lead tip transection, followed by trans-venous lead extraction.>

Introduction

Lead perforation is one of the serious complications associated with cardiac pacemakers (PM) and implantable cardiac defibrillators (ICDs) [1]. The reported overall lead perforation rates after PM and ICD are about 0.1–0.8% and 0.6–5.2%, respectively [2]. Such perforations can either be early (occurring during the first month after placement) or late (occurring more than one month after placement). Late perforation is an exceedingly rare complication and is usually more associated with actively fixed leads rather than passively fixed tined leads [3]. We identified 7 reported cases of late perforation of passively fixed tined device leads in the English literature. We present a case of blunt ended tined lead perforation after 4 months of implantation managed by a two-step hybrid minimally invasive approach consisting of mini-thoracotomy and lead tip transection, followed by trans-venous lead extraction.

Case report

An 80-year-old woman presented for routine follow-up of a dual chamber PM in June 2016, 4 months after implantation. During the visit, her right ventricle (RV) sensing and pacing thresholds were not obtainable.

The patient had past medical history of hypertension, anemia, chronic kidney disease, chronic obstructive pulmonary disease, hyperthyroidism, severe kyphosis, and chronic back pain. In February 2016, she complained of dizziness for a few weeks with associated near syncope and syncopal episodes. Telemetry at that time showed multiple sinus pauses with the longest pause lasting around 4.8 s. Echocardiogram showed mildly dilated left atrium, grade 1 pattern of left ventricular diastolic filling, left ventricular ejection fraction of 60–65%, and severe pulmonary hypertension. Right-sided chambers were normal in size.

A dual chamber PM (ADAPTA, Medtronic, Minneapolis, MN, USA) was implanted via the left cephalic vein. A passive fixation tined right ventricular lead (Medtronic, model: CapSure SP Novus 5092) was advanced to the RV apex, then a passive fixation tined atrial lead (Medtronic, model: CapSure SP Novus 5594) was advanced to the right atrium and placed in the right atrial appendage. The device was programmed to AAIR to DDDR mode at 60–130 beats per minute. Post implantation lead assessment showed that the sensed P waves were 3 mV, the sensed R waves were 11 mV. The atrial pacing threshold was 0.75 mV at 0.5 ms. The atrial pacing impedance was 450 Ohms. The RV pacing threshold was 0.5 V at 0.5 ms. The RV lead pacing impedance was 720 Ohms. Post-fixation portable chest X-ray showed the dual chamber PM with atrial and ventricular leads in customary position (Fig. 1).

Fig. 1.

Post-passive fixation chest X-ray of tined pacemaker leads.

One month after implantation, the patient presented to the emergency room with left-sided chest pain that was thought to be referred pain from her back and she was discharged home with pain control medication without any evaluation of her PM.

A chest X-ray ordered this visit showed lead migration (Fig. 2). Computed tomography (CT) scan of the chest confirmed the lead had perforated the RV apical myocardium and the pericardium with migration to the left chest under the subcostal muscles (Fig. 2). There was no pericardial effusion which was confirmed by echocardiography as well.

Fig. 2.

Chest X-ray and computed tomography scan of the chest showing lead perforation through the right ventricle.

Considering the probability that lead perforation occurred one month after implantation when she presented with her left upper chest pain, there was a concern for fibrosis around the tip of the tined lead or tip adherence. It was felt unsafe to do vascular lead extraction alone since the tined lead will likely worsen the perforation in the RV apex during the extraction. The decision was made to perform a hybrid procedure. The procedure was done under general anesthesia and transesophageal echocardiography (TEE) monitoring. First, a mini-thoracotomy was made and the lead tip was located and transected (Video 1 in Supplementary material). Then, an incision was made along the prior left pectoral PM incision scar. The proximal part of the old RV lead was freed and the lead was explanted without any complication. A new active fixation lead (Medtronic, model: CapSureFix Novus 5076) was implanted and secured in the proximal septum. The RV lead was programmed to an output of 3.5 V at 0.4 ms (milliseconds). The atrial lead was programmed to an output of 3.5 V at 0.4 ms. The device was programmed to AAIR to DDDR mode at 60–130 beats per minute. The paced AV delay was set at 150 ms. The sensed AV delay was set at 120 ms. The patient was discharged two days after the procedure with a normal echocardiogram and chest X-ray.

Discussion

Late perforation of PM or ICD leads is an extremely rare complication. It is probable that such a complication is more common in thin elderly women, and in patients who are taking steroids or anticoagulants [3], [4].

Perforation of tined pacemaker leads is even a rarer complication. We only found 7 reported cases of such complications in the English literature. In a large retrospective study by Lin et al. in 2015, patients who received new PMs from 1997 to 2011 were investigated for complications. Out of 29,250 patients with passively fixated leads, only 9 patients were reported to have late perforation (0.04%) [5]. In a literature review by Refaat et al. in 2010, 51 cases of late perforation were reviewed, in which only three patients had passively fixated tined leads [3].

Data of all cases found in the literature are represented in Table 1 [3], [6], [7], [8], [9]. Age range was 49–80 years (mean: 69.3 years). Five of the patients were females and six devices were PMs. Time of presentation ranged from 1 month to 36 months [mean: 14.1 months, standard deviation (SD): 15.4 months]. Chest pain was the presenting symptom in three cases, all had earlier presentations (1, 2, and 4 months). CT scan of the chest confirmed the diagnosis in 7 out of 8 cases.

Table 1.

Reported cases of late perforation of a tined device lead in the English literature.

Author	Age-gender	Type of device	Time to presentation	Presenting symptom	CT chest	Management
Refaat et al. [3]—case 1	75 M	PM-apex of Right heart	2 months	Intermittent chest pain	Tined lead outside RV	Open chest lead extraction
Refaat et al. [3]—case 2	60 F	ICD	36 months	Asymptomatic-accidentally discovered	Tined leads outside RV	TEE guided trans-venous extraction
Lopes et al. [6]	74 F	ICD	2 months	Recurrent syncopal episodes	Fluoroscopy showed migration of ventricular lead to extracardiac position	Trans-venous extraction
Sanoussi et al. [7]	79 F	PM-dual chamber	1 month	Chest pain	Ventricular lead in the subcutaneous fat underneath left breast	Mini-thoracotomy to cut the lead tip. Followed by trans-venous extraction
Celik et al. [8]—case 1	73 M	PM-bipolar tined tip leads	24 months	Hiccups	Tip of the lead was dislodged from the myocardium to the epicardial fat layer.	Open chest lead extraction
Celik et al. [8]—case 2	65 M	PM-bipolar tined tip leads	8 months	Worsening dyspnea	Tip of the lead perforated the inferior right ventricle apically	Open chest lead extraction
Haque et al. [9]	49 F	DDD PM	36 months	Pre-syncope	Tip of ventricular lead outside pericardium in the lung parenchyma	Open surgery to cut the lead tip, followed by trans-venous extraction
Demo et al.	80 F	PM	4 months	Left sided chest pain	Lead found under the left side subcostal muscles	Mini-thoracotomy to cut the lead tip. Followed by trans-venous extraction

PM: pacemaker; RV: right ventricle; ICD: implantable cardioverter defibrillator; TEE: trans-esophageal ECHO; DDD: dual chamber pacing and sensing, both triggered and inhibited mode.

Numbers in square parenthesis are references of the cases.

Management of the perforation ranged from trans-venous extraction used in two cases-one of them was TEE guided-up to open chest lead extraction performed in 3 cases. In one case, open surgery was done to cut the lead tip followed by trans-venous extraction. Two cases were managed successfully with a two-step hybrid procedure, starting with mini-thoracotomy to cut the lead tip, followed by trans-venous extraction of the lead.

When tined leads perforate into the myocardium and possibly pericardium, there is a huge concern that the bulky tip of the lead can damage tissues during removal. Single-step trans-venous extraction of perforated tined lead can be possibly done in the first months [6]. Fibrosis around the lead tip increases the risk of tissue damage with one-step extraction. Therefore, the usual approach has been a first step surgery to cut the distal tip, followed by trans-venous removal of the body of the lead.

Our case describes the successful 2-step hybrid approach for extraction of perforating tined leads, including mini-thoracotomy, transecting the lead tip, and trans-venous extraction. Safety of the procedure, avoidance of possible damage to the myocardium, and the use of mini-thoracotomy approach would favor the consideration of the procedure as the standard of care for management of such complications.

Funding

There is no funding for this case report.

Conflict of interest

There is no conflict of interest to declare.

Appendix A. Supplementary data

The following is Supplementary data to this article:

Video S1

Perforating lead tip through the pericardium.