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Ann Thorac Surg 2004;78:e83-e84
© 2004 The Society of Thoracic Surgeons

Case report

Pacemaker Lead Thrombosis Treated With Atrial Thrombectomy and Biventricular Pacemaker and Defibrillator Insertion

David B. Coleman, MDa, Dana M. DeBarr, BSa, David L. Morales, MDa, Henry M. Spotnitz, MD*,a

a Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA

Accepted for publication September 8, 2003.

* Address reprint requests to Dr Spotnitz, 622 W 168 St, PH 14-103, New York, NY 10032, USA
hms2{at}columbia.edu


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Right atrial thrombosis and pulmonary embolism are infrequent complications of pacemaker insertion. We report a patient with a large mobile thrombus on an endocardial DDD pacing lead and probable pulmonary embolism. We believe that this is the first case of pacemaker lead thrombosis in which treatment included insertion of an epicardial biventricular pacemaker and an implantable cardioverter-defibrillator.


   Introduction
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 Abstract
 Introduction
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Pacemaker lead thrombosis is a multifactorial problem amenable to a broad spectrum of therapy, ranging from anticoagulation to lead extraction. Infection or recurrent pulmonary embolism usually requires lead extraction. Lead thrombus is uniquely problematic in patients with pacemakers and heart failure who also require insertion of an implantable defibrillator. Recently, such patients may further benefit from epicardial leads for biventricular pacing. We present an interesting case that illustrates one current approach to management of this complex problem.

A 64-year-old man with coronary artery disease status post-percutaneous transluminal coronary angioplasty and dilated cardiomyopathy received a DDD pacemaker for second-degree heart block at an outside hospital. He presented to our institution with ventricular tachycardia and hemodynamic instability. Associated symptoms included chest pain and shortness of breath. He was resuscitated and transferred to the coronary care unit. Troponin peaked at 82 ng/mL. Electrocardiography revealed 100% ventricular pacing, QRS duration was 242 msec. A transthoracic echocardiogram demonstrated a 4-cm mobile thrombus in the right atrium (Fig 1). Estimated left ventricular ejection fraction was 25% to 30%. There was no evidence of endocarditis or acute venous stasis disease. Cardiac catheterization revealed a residual 40% stenosis at the site of the left anterior descending coronary artery stent and no other obstructive coronary disease.



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  		Fig 1. Intraoperative transesophageal echocardiogram. Arrow indicates thrombus adherent to pacemaker lead within the right atrium.

 
A ventilation and perfusion scan suggested pulmonary embolism, and we began anticoagulation. Serial echocardiograms demonstrated persistence of the thrombus, and repeat ventilation and perfusion scans suggested recurrent pulmonary embolism. The thrombus appeared adherent to the pacemaker leads. Atrial thrombectomy and lead extraction were recommended. The surgical plan also included placement of an epicardial DDD pacemaker and ICD. Biventricular pacing was elected in light of chronic symptoms of congestive heart failure associated with left ventricular ejection fraction less than 35% and QRS duration more than 120 msec.

On bypass, atriotomy revealed a 6 x 6 cm clot adherent to the leads at the junction of the right atrium and inferior vena cava. The pacemaker leads were divided and extracted with the majority of the adherent thrombus. An additional piece of thrombus was removed adjacent to the coronary sinus. The pacemaker generator and remaining leads were removed. The atrium was closed, and an epicardial DDD biventricular pacemaker and ICD were placed. Pacing thresholds were high, and ventricular pacing lead placement directed by thresholds was anterior right ventricle and diaphragmatic left ventricle. An ultrasound transit-time aortic flow meter was used to optimize cardiac output by adjusting the atrial–ventricular delay and pacing sites after weaning from bypass.

The patient was discharged after insertion of a subcutaneous array to correct high defibrillation thresholds. At follow-up, the patient reported decreased congestive heart failure symptomatology. Follow-up studies of ventricular function and coagulation status are planned.


   Comment
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 Abstract
 Introduction
 Comment
References
 
Intracardiac thrombosis associated with transvenous pacemaker leads has been reported in 24 patients in the English literature [1–21]. Patients presented acutely with congestive heart failure, shock, shortness of breath, or chest pain (n = 15); patients presented subacutely with malaise, cyanosis, edema, or pyrexia (n = 5); or patients present without symptoms (n = 4). Treatment modalities included medical management with anticoagulation or thrombolysis, or both (n = 10), treatment with thrombectomy and lead extraction (n = 6), or combined medical and surgical therapy (n = 4). There was one mortality among the patients treated medically, three mortalities among patients treated only with surgery, and no deaths among the patients treated both medically and surgically. The remainder of the patients had satisfactory recovery to hospital discharge and follow-up.

Our case is unique in that a biventricular pacemaker and ICD were placed at the time of right atrial thrombectomy. Biventricular pacing for dilated cardiomyopathy has been demonstrated to improve functional status and quality of life in three prospective randomized trials: (1) the Multisite Stimulation in Cardiomyopathy trial, (2) the Multicenter in Sync Randomized Clinical Evaluation trial, and (3) the Contak CD trial [22]. ICDs have been shown to offer improved survival to patients who have experienced hemodynamically significant arrhythmias or sudden cardiac death in three prospective randomized trials: (1) the Antiarrhythmics Versus Implantable Defibrillators trial, (2) the Cardiac Arrest Study Hamburg trial, and (3) the Canadian Implantable Defibrillator Study [23]. In our patient, placement of the biventricular pacing system and ICD at the time of thrombectomy and lead extraction allowed us to offer both an improved quality of life and survival with minimal additional surgical risk. Benefits of the epicardial approach included avoiding a presumed high risk of recurrent thrombosis if a new endocardial system had been inserted. An epicardial approach could also reduce the risk of recurrent infection in patients with endocarditis, which was not an issue in this case.

Right atrial thrombosis and pulmonary embolism are infrequent complications of transvenous pacemaker insertion. Symptomatic pulmonary embolism has been reported in 0.6% to 3.5% of patients [24]. Asymptomatic pulmonary embolism may occur at a much higher incidence (48%), which may be more likely in patients with ischemic or valvular heart disease, advanced age, and congestive heart failure [25]. Postoperative low-dose heparin may reduce the occurrence of asymptomatic pulmonary embolism [26].

The consequences of atrial thrombosis on pacemaker leads are potentially severe. The diagnosis should be considered in pacemaker recipients who experience hemodynamic decompensation with chest pain or shortness of breath. Transthoracic echocardiography and ventilation-perfusion scans are valuable diagnostic tools when considering this diagnosis. Treatment modalities include anticoagulation, thrombolysis, and surgery, either individually or a combination of these. The decision regarding which treatment plan to use should be individualized until more clinical data are available.


   References
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 Abstract
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This Article
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Right arrow Electrophysiology - arrhythmias

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