Ann Thorac Surg 2004;77:1077-1079
© 2004 The Society of Thoracic Surgeons
Case report
Ventricular tachycardia associated with transmyocardial migration of an epicardial pacing wire
David J. Meier, MDa,b,
Kamala P. Tamirisa, MDa,b,
Daniel T. Eitzman, MDa,b*
a The University of Michigan Health System, Department of Internal Medicine, Division of Cardiology, Ann Arbor, Michigan, USA
b Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
Accepted for publication April 9, 2003.
* Address reprint requests to Dr Eitzman, Division of Cardiology, 7301 MSRB III, 1150 W Medical Center Dr, Ann Arbor, MI 48109-0644, USA
e-mail: deitzman{at}umich.edu
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Abstract
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A 66-year-old man who had undergone a three-vessel coronary artery bypass grafting (CABG) procedure 3 years previously presented with ventricular tachycardia (VT) and cardiac arrest. Echocardiography demonstrated a wire coursing through the right ventricle into the pulmonary artery. The wire was removed with a snare and confirmed to be an epicardial temporary pacing wire placed during the CABG operation. We suspect that the epicardial pacing wire eroded through the right atrium and migrated into the right ventricle, contributing to the VT. Complications due to temporary epicardial pacing wires placed during CABG are discussed.
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Introduction
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Since the mid-1960s, temporary atrial and ventricular epicardial pacing wires have been routinely placed during cardiac surgical procedures to assist in maintaining optimal hemodynamics in the early postoperative period [1]. The safety and efficacy of these epicardial pacing wires have been generally accepted, and their use is common after cardiac procedures. However, it is important to recognize that complications do occur, both in the immediate postoperative period and up to many years after the operation. We describe a case of the transmyocardial migration of an epicardial pacing wire into the right ventricle and pulmonary artery. This was discovered after the patient presented with ventricular tachycardia (VT) 3 years after epicardial wire placement.
A 66-year-old man with coronary artery disease (CAD) who had undergone a three-vessel coronary artery bypass grafting (CABG) procedure in 1999 presented to an outside hospital in 2002 with respiratory distress that progressed to full cardiopulmonary arrest requiring intubation. Monomorphic VT was documented at presentation, and the patient was successfully cardioverted to sinus rhythm. A myocardial infarction was ruled out, and the patient was extubated the following day. Cardiac catheterization revealed severe native three-vessel CAD with one patent saphenous vein bypass graft to a large first diagonal branch and moderate left ventricular (LV) dysfunction. On day 4 of hospitalization, the patient experienced an episode of near syncope associated with palpitations. He was then transferred to our institution for further evaluation. On arrival, his vital signs were stable. An electrocardiogram revealed normal sinus rhythm, with a previously documented left bundle branch block. Because of LV dysfunction and documented VT associated with cardiac arrest, the patient was scheduled for the implantation of a cardiac defibrillator. The procedure was delayed because of an episode of fever with leukocytosis. A transesophageal echocardiogram revealed no valvular vegetations, but a wire was noted passing through the right atrium, right ventricle, and into the pulmonary artery (Fig 1). No central line was present at this time. Fluoroscopy revealed epicardial wires retained from his CABG operation in 1999 and a wire of the same caliber that appeared to course through the right ventricular outflow tract into the pulmonary artery. The intracardiac position and course of the wire were also confirmed with a chest computed tomography scan. Because the intracardiac position of the wire may have contributed to the VT and cardiac arrest, the wire was extracted with a 35-mm Amplatz gooseneck snare (Microvena, White Bear Lake, MN). Of interest, nonsustained monomorphic VT occurred during wire manipulation. The wire measured 16 cm in length and was identified as an Ethicon TPW 32 2.0 x 60 cm unipolar epicardial pacing wire (Ethicon, Somerville, NJ) (Fig 2). We confirmed that this was the wire placed during his CABG operation 3 years previously. Because of the patient's LV dysfunction, he was still considered to be at high risk for sudden cardiac death and underwent successful defibrillator implantation. The patient has done well, with no palpitations since discharge.
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Fig 1. Transesophageal echocardiogram demonstrating wire passing through right ventricle into proximal pulmonary artery. Arrows identify wire. (AV = aortic valve; LA = left atrium; LVOT = left ventricular outflow track; PA = pulmonary artery; RVOT = right ventricular outflow track.)
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Comment
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Complications of epicardial pacing wires placed during cardiac surgical procedures occur in approximately 0.09% of patients [2]. Complications may be associated with the placement, removal, and retention of the epicardial pacing wires. In one of the earliest experiences with epicardial wires, Hodam and Starr [1] reported four complications attributed to the use of epicardial pacing wires in a series of 1000 patients who underwent cardiac surgical procedures. These were due to wire erosions into adjacent structures, including coronary arteries, the aorta, and pleural cavities, resulting in bleeding complications and pneumothoraces. The insertion of epicardial wires has been associated with the perforation of the right ventricle, leading to cardiac tamponade [2]. The removal of epicardial pacing wires has also been associated with the laceration of vascular structures, leading to cardiac tamponade and hemothorax [2].
Patients are at risk for ventricular arrhythmias during pacing wire removal. One study reported that 7% of patients experienced nonsustained VT during wire removal, and 66% of patients had at least one premature ventricular contraction (PVC) [3]. Another study reported that 20% of patients experienced bigeminy and multiform PVCs [4].
Several case reports have described complications from wire retention and migration. In one patient, a wire was noted to have migrated through a bronchus and present as a posterior mediastinal mass 9 months after an episode of hemoptysis [5]. The migration of the retained fragment of an epicardial wire into the free peritoneal cavity was reported in another patient 6 years after a cardiac surgical procedure [6]. Infectious complications, including prosthetic valve endocarditis secondary to infection of the retained pacing wire with repeated episodes of bacteremia, have also been reported [7].
Our report describes an epicardial pacing wire migrating into the cardiac chambers. Our case is particularly interesting, because this was discovered after an episode of VT and cardiac arrest. Although this patient had several risk factors for cardiac arrest, it is also conceivable that the epicardial wire contributed to his VT. On the basis of a careful examination of the imaging studies, we believe that the retrieved wire originated from the right atrial wall. Right atrial tissue is relatively thin and easily penetrated. The subsequent migration of the wire through the right-sided cardiac chambers and into the proximal pulmonary artery was likely due to hemodynamic forces associated with blood flow. The snare method used to retrieve the wire has been applied to multiple intravascular foreign bodies, including guidewire fragments, catheter fragments, vena cava filters, embolization catheters, knotted Swan-Ganz catheters, and even bullets [8]. Although the migration of a retained wire is probably a relatively rare event, this report highlights yet another complication associated with the use of postoperative epicardial wires that should be considered when weighing their risks and their benefits.
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References
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- Hodam R.P., Starr A. Temporary postoperative epicardial pacing electrodes. Ann Thorac Surg 1969;8:506-510.[Medline]
- Del Nido P., Goldman B.S. Temporary epicardial pacing after open heart surgery: complications and prevention. J Cardiac Surg 1989;4(1):99-103.[Medline]
- Carroll K.C., Reeves L.M., Andersen G., Ray F.M., Clopton P.L., Shively M., Tarazi R.Y. Risks associated with removal of ventricular epicardial pacing wires after cardiac surgery. Am J Critical Care 1998;7(6):444-449.
- Harjula A., Jarvinen A., Mattila S., Hartel G. Removal of monofilament and multifilament temporary pacing leads following open-heart surgery: occurrence of arrhythmias. Pace 1985;8:607-610.
- Gentry W.H., Hassan A.A. Complications of retained epicardial pacing wires: an unusual bronchial foreign body. Ann Thorac Surg 1993;56:1391-1393.[Abstract]
- Korompai F.L., Hayward R.H., Knight W.L. Migration of temporary epicardial pacer wire fragment retained after a cardiac operation. J Thorac Cardiovasc Surg 1987;94(3):446-447.[Abstract]
- Mansur A.J., Grinberg M., Costa R., Chung C.V., Pileggi F. Dura mater valve endocarditis related to retained fragment of postoperative temporary epicardial pacemaker lead. Am Heart J 1984;108(4 part 1):1049-1050.[Medline]
- Gabelmann A., Kramer S., Gorich J. Percutaneous retrieval of lost or misplaced intravascular objects. Am J Roentgenol 2001;176:1509-1513.[Abstract/Free Full Text]
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Abstract
Introduction
