Incidental Extraction of a Temporary Epicardial Pacemaker Wire With Right Ventricular Perforation During Endomyocardial Biopsy: A Case Report B. Skoric*, J. Samardzic, M. Cikes, Z. Baricevic, H. Jurin, J. Ljubas-Macek, and D. Milicic University of Zagreb School of Medicine, Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
ABSTRACT Introduction. Right ventricular perforation during endomyocardial biopsy is an unusual, although potentially life-threatening, complication caused with the tip of the bioptome. The majority of perforations in heart transplant patients can be managed without surgery owing to adhesions nearly obliterating pericardial space. Case Report. We report a case of heart transplant patient who suffered right ventricular perforation as a consequence of incidental extraction of a temporary epicardial pacemaker wire during a routine endomyocardial biopsy sampling. Conclusions. The patient suffered no clinical consequences.
E
NDOMYOCARDIAL BIOPSY (EMB) is a relatively safe, invasive tool used for surveillance of cardiac allograft rejection as well as in the evaluation of myocardial disease. Nevertheless, cardiac perforation may occur and can be lethal. It is a real challenge to manage this clinical emergency, although from clinical experience it seems that the risk of pericardial tamponade is small because the pericardial space has been practically obliterated and the right ventricular perforations are contained by the pericardium. The risk for this complication is lower 3 months after cardiac surgery, by which time the pericardial adhesions to the myocardium should be formed. The cardiac perforation during EMB is typically caused by the tip of bioptome. We present a case of heart transplant patient who suffered right ventricular perforation as a consequence of incidental extraction of a temporary epicardial pacemaker wire during a routine EMB.
CASE REPORT A 51-year-old man was admitted for a routine control EMB 3 months after undergoing heart transplantation. During the posttransplant period, no significant arrhythmia was observed and the surgeon removed epicardial wires by external traction with no complications. Soon after discharge, the patient started to complain of exercise intolerance. Echocardiography was normal and EMB showed no rejection. However, a profound sinus bradycardia with pauses of 7 seconds was observed on Holter recording and the chronotropic incompetence was confirmed during the stress test. 0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.02.012
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After the transvenous implantation of Medtronic Sensia DDDR permanent pacemaker the patient recuperated. Biopsy was performed under local anesthesia through the right femoral vein. Using the Seldinger technique, we introduced a long sheath with Pigtail catheter (7-French/98 cm; Cordis) into the right ventricle. After the Pigtail catheter was pulled out, a Cordis bioptome (7 Fr/104 cm/2.2 mm jaw) was introduced through the sheath into the right ventricle under the fluoroscopic surveillance. After 3 endomyocardial specimens were taken, we went for the next one. The jaws of the bioptome were opened and gentle forward pressure was maintained while the jaws were closed. The bioptome was then removed by traction. The initial resistance suddenly vanished and the bioptome leapt into the sheath. To our surprise, the jaws of retracted bioptome held a temporary epicardial pacing wire (4968e35 cm, Medtronic) retained from the previous cardiac surgery (Fig 1). The patient was asymptomatic, but nonetheless we assumed that there was a perforation of the right ventricular wall with the long sheath that was sealing the perforation at the same time. We gave some iodine contrast through the long sheath and the extravasation of contrast into the pericardial space was obvious (Fig 2). Immediate arterial cannulation for invasive blood pressure measurement was done. With cardiac surgery backup and under both fluoroscopic and ultrasound surveillance, we pulled out the sheath without any symptoms, hemodynamic changes, or *Address correspondence to Bosko Skoric, MD, PhD, University of Zagreb School of Medicine, Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Kispaticeva 12, 10 000 Zagreb, Croatia. E-mail: [email protected] ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
Transplantation Proceedings, 47, 844e845 (2015)
EXTRACTION OF A PACEMAKER WIRE
845
Fig 1. The bioptome with the extracted temporary epicardial pacing wire. development of pericardial effusion. The patient was monitored for the next 24 hours and was discharged 3 days later.
DISCUSSION
The rate of right ventricular perforation caused by a bioptome catheter during EMB is 0.05%e5% and leads to tamponade in fewer than one-half of cases [1]. The risk of myocardial perforation was proportional to the severity of ventricular dilatation. However, mortality is low and the majority of perforations can be managed without pericardiocentesis and/or surgery, but with careful patient monitoring. There are many reported cases of perforations caused by temporary transvenous pacemaker catheters (5 and 6 Fr), with some of them left for even 5 days, and no consequences after withdrawal [2]. Withdrawal of the perforating catheters seems to be dangerous if the perforation occurs with delay or when the symptoms of cardiac tamponade appear before withdrawal. The perforation in our patient was owing to the long sheath pulling into the pericardial space while the bioptome was retrieving the epicardial wire. Despite the fact that the sheath was 7 Fr, its withdrawal went without tamponade, probably owing to the normal right ventricular muscle wall, pericardial adhesions
Fig 2. The extravasation of contrast with the long sheath left in the pericardial space.
to the myocardium after cardiac surgery, and very short time that the sheath was left at the perforation site. In conclusion, to our knowledge, this is the first case of myocardial perforation caused by incidental extraction of a temporary epicardial pacemaker wire as a complication of EMB. In heart transplant patients, perforation can be safely managed conservatively. Positioning the bioptome toward the interventricular septum during EMB reduces the risk of such complications. REFERENCES [1] Saraiva F, Matos V, Goncalves L, et al. Complications of endomyocardial biopsy in heart transplant patients: a retrospective study of 2117 consecutive procedures. Transplant Proc 2011;43: 1908e12. [2] Meyer JA, Millar K. Perforation of the right ventricle by electrode catheters: a review and report of nine cases. Ann Surg 1968;168:1048e60.
ABSTRACT Introduction. Right ventricular perforation during endomyocardial biopsy is an unusual, although potentially life-threatening, complication caused with the tip of the bioptome. The majority of perforations in heart transplant patients can be managed without surgery owing to adhesions nearly obliterating pericardial space. Case Report. We report a case of heart transplant patient who suffered right ventricular perforation as a consequence of incidental extraction of a temporary epicardial pacemaker wire during a routine endomyocardial biopsy sampling. Conclusions. The patient suffered no clinical consequences.
E
NDOMYOCARDIAL BIOPSY (EMB) is a relatively safe, invasive tool used for surveillance of cardiac allograft rejection as well as in the evaluation of myocardial disease. Nevertheless, cardiac perforation may occur and can be lethal. It is a real challenge to manage this clinical emergency, although from clinical experience it seems that the risk of pericardial tamponade is small because the pericardial space has been practically obliterated and the right ventricular perforations are contained by the pericardium. The risk for this complication is lower 3 months after cardiac surgery, by which time the pericardial adhesions to the myocardium should be formed. The cardiac perforation during EMB is typically caused by the tip of bioptome. We present a case of heart transplant patient who suffered right ventricular perforation as a consequence of incidental extraction of a temporary epicardial pacemaker wire during a routine EMB.
CASE REPORT A 51-year-old man was admitted for a routine control EMB 3 months after undergoing heart transplantation. During the posttransplant period, no significant arrhythmia was observed and the surgeon removed epicardial wires by external traction with no complications. Soon after discharge, the patient started to complain of exercise intolerance. Echocardiography was normal and EMB showed no rejection. However, a profound sinus bradycardia with pauses of 7 seconds was observed on Holter recording and the chronotropic incompetence was confirmed during the stress test. 0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.02.012
844
After the transvenous implantation of Medtronic Sensia DDDR permanent pacemaker the patient recuperated. Biopsy was performed under local anesthesia through the right femoral vein. Using the Seldinger technique, we introduced a long sheath with Pigtail catheter (7-French/98 cm; Cordis) into the right ventricle. After the Pigtail catheter was pulled out, a Cordis bioptome (7 Fr/104 cm/2.2 mm jaw) was introduced through the sheath into the right ventricle under the fluoroscopic surveillance. After 3 endomyocardial specimens were taken, we went for the next one. The jaws of the bioptome were opened and gentle forward pressure was maintained while the jaws were closed. The bioptome was then removed by traction. The initial resistance suddenly vanished and the bioptome leapt into the sheath. To our surprise, the jaws of retracted bioptome held a temporary epicardial pacing wire (4968e35 cm, Medtronic) retained from the previous cardiac surgery (Fig 1). The patient was asymptomatic, but nonetheless we assumed that there was a perforation of the right ventricular wall with the long sheath that was sealing the perforation at the same time. We gave some iodine contrast through the long sheath and the extravasation of contrast into the pericardial space was obvious (Fig 2). Immediate arterial cannulation for invasive blood pressure measurement was done. With cardiac surgery backup and under both fluoroscopic and ultrasound surveillance, we pulled out the sheath without any symptoms, hemodynamic changes, or *Address correspondence to Bosko Skoric, MD, PhD, University of Zagreb School of Medicine, Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Kispaticeva 12, 10 000 Zagreb, Croatia. E-mail: [email protected] ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
Transplantation Proceedings, 47, 844e845 (2015)
EXTRACTION OF A PACEMAKER WIRE
845
Fig 1. The bioptome with the extracted temporary epicardial pacing wire. development of pericardial effusion. The patient was monitored for the next 24 hours and was discharged 3 days later.
DISCUSSION
The rate of right ventricular perforation caused by a bioptome catheter during EMB is 0.05%e5% and leads to tamponade in fewer than one-half of cases [1]. The risk of myocardial perforation was proportional to the severity of ventricular dilatation. However, mortality is low and the majority of perforations can be managed without pericardiocentesis and/or surgery, but with careful patient monitoring. There are many reported cases of perforations caused by temporary transvenous pacemaker catheters (5 and 6 Fr), with some of them left for even 5 days, and no consequences after withdrawal [2]. Withdrawal of the perforating catheters seems to be dangerous if the perforation occurs with delay or when the symptoms of cardiac tamponade appear before withdrawal. The perforation in our patient was owing to the long sheath pulling into the pericardial space while the bioptome was retrieving the epicardial wire. Despite the fact that the sheath was 7 Fr, its withdrawal went without tamponade, probably owing to the normal right ventricular muscle wall, pericardial adhesions
Fig 2. The extravasation of contrast with the long sheath left in the pericardial space.
to the myocardium after cardiac surgery, and very short time that the sheath was left at the perforation site. In conclusion, to our knowledge, this is the first case of myocardial perforation caused by incidental extraction of a temporary epicardial pacemaker wire as a complication of EMB. In heart transplant patients, perforation can be safely managed conservatively. Positioning the bioptome toward the interventricular septum during EMB reduces the risk of such complications. REFERENCES [1] Saraiva F, Matos V, Goncalves L, et al. Complications of endomyocardial biopsy in heart transplant patients: a retrospective study of 2117 consecutive procedures. Transplant Proc 2011;43: 1908e12. [2] Meyer JA, Millar K. Perforation of the right ventricle by electrode catheters: a review and report of nine cases. Ann Surg 1968;168:1048e60.
