Catheterization and Cardiovascular Diagnosis 21 :9!j-96 (1990)
Unusual Case of Pacemaker Lead Migration B.V. Dalvi, DM, R.M. Rajani, MD, Y.Y. Lokhandwala, MD, S.V. Sathe, DM, H.L. Kulkarni, DM, and P.A. Kale MD Pulmonary artery migration of pacemaker lead is rare and may result in pulmonary emboli originating from the thrombus around the infected catheter and causing multiple pulmonary infarcts. We report an unusual case of pacemaker lead migration to the right pulmonary artery with septic pulmonary embolism. While being treated with intravenous Cefuroxamine, the patient had spontaneous migration of the lead to the left pulmonary artery with subsequent lefl pulmonary embolism. Key words: unusual sites, pulmonary artery branches, pacemaker complication
INTRODUCTION With more frequent use of permanent pacemakers, many complications in the form of lead displacement. electrode fractures, atrial thrombi. pulmonary embolism. and myocardial perforation have been reported. We present an unusual case of pacemaker lead migration into the pulmonary artery branches.
CASE REPORT A 33-year-old male patient with recurrent syncope and evidence of intermittent sinus arrest and sinoatrial blocks on the electrocardiogram underwent permanent pacemaker implantation through the right cephalic vein in February 1984. With a normally functioning pacemaker, he was completely asymptomatic during follow-up visits. Four years after implantation, he presented with dehiscence of the pacemaker pocket and extrusion of the generator. Explantation of the pacemaker generator, with a view to implant it at another site, was carried out. The lead could not be retrieved. as it was firmly adherent to the right ventricular apex. It was therefore severed at its entry into the right cephalic vein. and the proximal end was secured with nonabsorbable sutures. Thereafter the patient refused permanent pacemaker implantation at the other site and had to be discharged. Fortunately, his heart rate on discharge was adequate to keep him symptom free. Six months later, he presented with high-grade fever and chills. X-ray chest revealed a pneumatocele at the base of the right lung. The distal end of the lead was seen to lie at the right ventricular apex, whereas the proximal end of the lead migrated into the right pulmonary artery (Fig. I ) . Blood cultures grew staphylococci sensitive to Cefuroxime. The patient responded to intravenous Cefuroxime. While still on therapy. he developed left-sided 0 1990 Wiley-Liss, Inc.
chest pain and hemoptysis. Clinical examination revealed the presence of a left basal pleural rub. Repeat x-ray of the chest showed migration of the proximal end of the lead into the left pulmonary artery in the absence of any manouveres or manipulations in the intervening period (Fig. 2). There was a haziness in the left basal zone. Because the lead was a source of continued infection and thrombus formation, operative removal of the lead and permanent pacemaker implantation with epimyocardial lead were advised.
DISCUSSION Migration of improperly secured transvenous catheters is not uncommon [ I ] . Embolization of polyethylene catheters into the pulmonary vasculature has been reported 121. However, pulmonary artery migration of a pacemaker lead as seen in our case is rather unusual. Leads have been observed to migrate into the lower half of the body such as inferior vena cava or the hepatic venous system probably because of their higher specific gravity 131. However, in a rare instance, as in the present case, they might migrate in the pulmonary artery possibly due to peculiar body position at the time of migration. Detachment of a proximally severed and sutured lead and its subsequent migration is very rare in the absence of an infection and is due to inadequate fixation at its venous entrance. However, loosening of securing sutures From the Department of Cardiology, King Edward VII Memorial Hospital, Parel, Bombay. Received February 14. 1990; revision accepted June 5, 1990. Address reprint requests to Bharat Dalvi, Lecturer. Department of Cardiology, King Edward V11 Memorial Hospital, Parel, Bombay 400 012, India.
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Fig. 2. The electrode catheter migrating into the left pulmonary artery (arrow). Fig. 1. Migration of the pacemaker electrode catheter into the right pulmonary artery (arrow).
cannot be prevented in the presence of local infection, as in our case [3]. The presence of transvenous electrode within the cardiovascular system provokes a fibrous endothelial reaction, which forms a kind of “neoendothelium” around the catheter in the venous tract and the heart [3]. This renders the removal of catheter from the ventricular myocardium difficult or even impossible, especially beyond 6 to 8 weeks after insertion [3]. Forceful manouevring of the catheter may lead to ventricular arrhythmias, shock, intracardiac lead fracture, and arteriovenous fistulas [3]. In view of these risks, prolonged or forceful traction is practically given up, and this policy seems particularly justified for retained electrodes without accompanying infection. This prompted us to leave the lead behind without manipulations. Noninfected, functionless leads can be left in situ over many years without causing any functional abnormalities [4]. However, the presence of an electrode in the vascular system may act as a nidus for thrombus formation [ 5 ] . If infection reaches the vascular system, most commonly through skin ulceration over the pacemaker generator, as in our case, serious complications in the form of fatal infective endocarditis [6], septicemia, and pulmonary embolism may supervene. Such
complications should prompt urgent removal of the electrode. Two modes have been described for the removal of the embolized catheters [7]: thoracotomy or transvenous retrieval. Thoracotomy is associated with significant morbidity and mortality. The existence of transvenous devices for removal of catheter emboli in the form of loop snares, grasping forceps, and basket catheters have relegated surgery to a secondary role. REFERENCES I . Bernhardt LC, Wegner GP, Mendenhall J T Intravenous catheter embolization to the pulmonary artery. Chest 57:329-332, 1970. 2. Miller RE, Cockerill EM, Helbig H:Percutaneous removal of catheter emboli from pulmonary arteries. Radiology 94: 151-153, 1970. 3. Rettig G. Doenecke P, Sen S, Volkmer I, Betta L: Complications with retained transvenous pacemaker electrodes. Am Heart J 98: 587-594, 1979. 4. Furman S, Escher DJW: Retained endocardial pacemaker electrodes. J Thorac Cardiovasc Surg 55:737-740. 1968. 5. Becker AE. Becker JM, Martin FH, Edwards JE: Bland thrombosis and infection in relation to intracardiac catheter. Circulation 46: 200-203, 1972. 6. Davis JM. Moss AJ. Schenk EA: Tricuspid candida endocarditis
complicating a permanently implanted transvenous pacemaker. Am Heart J 77:818-821, 1969. 7. Dhingra RC, Rosen KM,Rahimtoola SH: Transvenous removal of catheter fragments from the heart and pulmonary artery. Arch Int Med 132:419-421, 1973.
Unusual Case of Pacemaker Lead Migration B.V. Dalvi, DM, R.M. Rajani, MD, Y.Y. Lokhandwala, MD, S.V. Sathe, DM, H.L. Kulkarni, DM, and P.A. Kale MD Pulmonary artery migration of pacemaker lead is rare and may result in pulmonary emboli originating from the thrombus around the infected catheter and causing multiple pulmonary infarcts. We report an unusual case of pacemaker lead migration to the right pulmonary artery with septic pulmonary embolism. While being treated with intravenous Cefuroxamine, the patient had spontaneous migration of the lead to the left pulmonary artery with subsequent lefl pulmonary embolism. Key words: unusual sites, pulmonary artery branches, pacemaker complication
INTRODUCTION With more frequent use of permanent pacemakers, many complications in the form of lead displacement. electrode fractures, atrial thrombi. pulmonary embolism. and myocardial perforation have been reported. We present an unusual case of pacemaker lead migration into the pulmonary artery branches.
CASE REPORT A 33-year-old male patient with recurrent syncope and evidence of intermittent sinus arrest and sinoatrial blocks on the electrocardiogram underwent permanent pacemaker implantation through the right cephalic vein in February 1984. With a normally functioning pacemaker, he was completely asymptomatic during follow-up visits. Four years after implantation, he presented with dehiscence of the pacemaker pocket and extrusion of the generator. Explantation of the pacemaker generator, with a view to implant it at another site, was carried out. The lead could not be retrieved. as it was firmly adherent to the right ventricular apex. It was therefore severed at its entry into the right cephalic vein. and the proximal end was secured with nonabsorbable sutures. Thereafter the patient refused permanent pacemaker implantation at the other site and had to be discharged. Fortunately, his heart rate on discharge was adequate to keep him symptom free. Six months later, he presented with high-grade fever and chills. X-ray chest revealed a pneumatocele at the base of the right lung. The distal end of the lead was seen to lie at the right ventricular apex, whereas the proximal end of the lead migrated into the right pulmonary artery (Fig. I ) . Blood cultures grew staphylococci sensitive to Cefuroxime. The patient responded to intravenous Cefuroxime. While still on therapy. he developed left-sided 0 1990 Wiley-Liss, Inc.
chest pain and hemoptysis. Clinical examination revealed the presence of a left basal pleural rub. Repeat x-ray of the chest showed migration of the proximal end of the lead into the left pulmonary artery in the absence of any manouveres or manipulations in the intervening period (Fig. 2). There was a haziness in the left basal zone. Because the lead was a source of continued infection and thrombus formation, operative removal of the lead and permanent pacemaker implantation with epimyocardial lead were advised.
DISCUSSION Migration of improperly secured transvenous catheters is not uncommon [ I ] . Embolization of polyethylene catheters into the pulmonary vasculature has been reported 121. However, pulmonary artery migration of a pacemaker lead as seen in our case is rather unusual. Leads have been observed to migrate into the lower half of the body such as inferior vena cava or the hepatic venous system probably because of their higher specific gravity 131. However, in a rare instance, as in the present case, they might migrate in the pulmonary artery possibly due to peculiar body position at the time of migration. Detachment of a proximally severed and sutured lead and its subsequent migration is very rare in the absence of an infection and is due to inadequate fixation at its venous entrance. However, loosening of securing sutures From the Department of Cardiology, King Edward VII Memorial Hospital, Parel, Bombay. Received February 14. 1990; revision accepted June 5, 1990. Address reprint requests to Bharat Dalvi, Lecturer. Department of Cardiology, King Edward V11 Memorial Hospital, Parel, Bombay 400 012, India.
96
Dalvi et al.
Fig. 2. The electrode catheter migrating into the left pulmonary artery (arrow). Fig. 1. Migration of the pacemaker electrode catheter into the right pulmonary artery (arrow).
cannot be prevented in the presence of local infection, as in our case [3]. The presence of transvenous electrode within the cardiovascular system provokes a fibrous endothelial reaction, which forms a kind of “neoendothelium” around the catheter in the venous tract and the heart [3]. This renders the removal of catheter from the ventricular myocardium difficult or even impossible, especially beyond 6 to 8 weeks after insertion [3]. Forceful manouevring of the catheter may lead to ventricular arrhythmias, shock, intracardiac lead fracture, and arteriovenous fistulas [3]. In view of these risks, prolonged or forceful traction is practically given up, and this policy seems particularly justified for retained electrodes without accompanying infection. This prompted us to leave the lead behind without manipulations. Noninfected, functionless leads can be left in situ over many years without causing any functional abnormalities [4]. However, the presence of an electrode in the vascular system may act as a nidus for thrombus formation [ 5 ] . If infection reaches the vascular system, most commonly through skin ulceration over the pacemaker generator, as in our case, serious complications in the form of fatal infective endocarditis [6], septicemia, and pulmonary embolism may supervene. Such
complications should prompt urgent removal of the electrode. Two modes have been described for the removal of the embolized catheters [7]: thoracotomy or transvenous retrieval. Thoracotomy is associated with significant morbidity and mortality. The existence of transvenous devices for removal of catheter emboli in the form of loop snares, grasping forceps, and basket catheters have relegated surgery to a secondary role. REFERENCES I . Bernhardt LC, Wegner GP, Mendenhall J T Intravenous catheter embolization to the pulmonary artery. Chest 57:329-332, 1970. 2. Miller RE, Cockerill EM, Helbig H:Percutaneous removal of catheter emboli from pulmonary arteries. Radiology 94: 151-153, 1970. 3. Rettig G. Doenecke P, Sen S, Volkmer I, Betta L: Complications with retained transvenous pacemaker electrodes. Am Heart J 98: 587-594, 1979. 4. Furman S, Escher DJW: Retained endocardial pacemaker electrodes. J Thorac Cardiovasc Surg 55:737-740. 1968. 5. Becker AE. Becker JM, Martin FH, Edwards JE: Bland thrombosis and infection in relation to intracardiac catheter. Circulation 46: 200-203, 1972. 6. Davis JM. Moss AJ. Schenk EA: Tricuspid candida endocarditis
complicating a permanently implanted transvenous pacemaker. Am Heart J 77:818-821, 1969. 7. Dhingra RC, Rosen KM,Rahimtoola SH: Transvenous removal of catheter fragments from the heart and pulmonary artery. Arch Int Med 132:419-421, 1973.
