Ann Thorac Surg 2008;86:1352-1354. doi:10.1016/j.athoracsur.2008.03.013
© 2008 The Society of Thoracic Surgeons
Case Reports
Progressive Dyspnea After CABG: Complication of Retained Epicardial Pacing Wires
George S. Horng, MDa,*,
Euan Ashley, MB, ChB, DPhilb,
Leora Balsam, MDc,
Bruce Reitz, MDc,
Roham T. Zamanian, MDa,d
a Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Stanford, California
b Division of Cardiology, Stanford University Medical Center, Stanford, California
c Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California
d Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University Medical Center, Stanford, California
Accepted for publication March 6, 2008.
* Address correspondence to Dr Horng, Division of Pulmonary & Critical Care Medicine, Stanford University School of Medicine, 300 Pasteur Dr, Room H3143, Stanford, CA 94305 (Email: gsh{at}stanford.edu).
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Abstract
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We report a case of progressive dyspnea and recurrent pneumonia after uneventful coronary artery bypass graft surgery caused by migration of retained epicardial pacing wires into the right upper lobe of the lung. Removal of the wires by open thoracotomy resulted in significant improvement in dyspnea and near complete resolution of the bronchiectasis and consolidation.
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Introduction
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Epicardial pacing wires are routinely placed during open cardiac operations to diagnose and treat postoperative arrhythmias. The overall incidence of major complications is low (0.4%), with most complications related to the placement or removal of the wires [1]. We report a case of retained temporary epicardial pacing wires that migrated into the right upper lobe of the lung and caused endobronchial obstruction with recurrent pneumonia and bronchiectasis.
A 60-year-old man with hypertension, atrial fibrillation, and coronary artery disease status post three-vessel coronary artery bypass grafting (CABG) surgery 6 years prior was referred for evaluation of chronic cough, progressive shortness of breath, and recurrent pneumonia. The patient underwent emergent CABG surgery (left internal mammary artery to left anterior descending artery, saphenous vein graft to ramus artery, saphenous vein graft to obtuse marginal artery) after an inferior myocardial infarction and ventricular fibrillation arrest in the field. There were no perioperative or postoperative complications reported. Temporary epicardial pacing wires placed at the right atrium and right ventricle were difficult to remove postoperatively and thus were clipped and left in place. The immediate postoperative course was unremarkable, but the next several years were noteworthy for episodic unexplained pneumonia and progressive dyspnea. Eventually, the patient was referred to our center for cardiopulmonary evaluation and potential consideration for heart transplantation given the unremitting dyspnea.
Extensive cardiovascular work-up for his symptoms, including stress echocardiogram, cardiopulmonary exercise testing, and 24-hr Holter monitoring revealed normal systolic and valvular cardiac function, no significant elevation in pulmonary artery pressures with exercise, and no evidence of inducible ischemia. However, the breathing reserve at maximal exercise was less than 50%, consistent with mild mechanical limitation to pulmonary function. In addition, VO2max was significantly limited (16 mL/kg/min, 62% predicted) in the absence of a clear cardiac cause. As a result, the patient underwent computed tomographic imaging of his thorax, which showed consolidation within the anterior and posterior segments of the right upper lobe with bronchiectasis, architectural distortion, and mild volume loss. In addition, a band-like area of consolidation was seen surrounding an epicardial wire that had migrated into the right upper lobe (Fig 1A).
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Fig 1. (A) Computed tomographic image of the thorax in the axial section shows epicardial pacing wire (white) in right upper lobe of the lung and associated lung consolidation. (B) Endobronchial view of right upper lobe bronchus shows blue pacing wire crossing the bronchial lumen.
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A flexible fiberoptic bronchoscopy was performed and visualized a pacing wire crossing the lumen of the right upper lobe bronchus (Fig 1B). The retained epicardial pacing wire created an endobronchial obstruction with resultant bronchiectasis and recurrent post-obstructive pneumonia that accounted for the patient's respiratory symptoms. Bronchoscopic or thorascopic removal of the wires was initially considered. However, due to the long duration that the wires had been in place (> 6 years), as well as the location of the wires deep in the pulmonary parenchyma, the risk for potential bleeding complications was deemed excessive, and the patient was taken electively to the operating room for right anterolateral thoracotomy. The thorax was entered at the level of the fourth intercostal space, pericardium opened longitudinally parallel to the course of the phrenic nerve, and two epicardial pacing wires were isolated. The leads were extracted without complications and the patient had an uneventful recovery (Fig 2A).
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Fig 2. (A) Epicardial pacing wires are shown after removal (6-inch ruler used as reference). (B) Computed tomographic image of the thorax in the axial section shows near resolution of right upper lobe consolidation after epicardial pacing wire removal.
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In a follow-up visit 3 months after the thoracotomy, the patient reported significant improvement in his dyspnea and no longer required regular use of inhaled bronchodilators. Computed tomographic imaging of his thorax showed marked improvement in the right upper lobe with minimal residual consolidation (Fig 2B).
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Comment
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Temporary epicardial pacing wires are commonly used in patients undergoing open cardiac surgery. Major complications related to wire removal include cardiac tamponade due to atrial or ventricular laceration, laceration of saphenous vein graft, and cardiac entrapment by the wire [2–4]. Difficulties encountered during wire removal often lead to the physician clipping the wires and leaving them in place with the assumption that the risks of removal outweigh the risks of retention.
Complications related to retained epicardial pacing wire are rare but can have significant morbidity. Patients usually present with symptoms and findings related to migration of the wire. Previously reported thoracic complications include mediastinal mass due to migration into the right lower lobe bronchus, prosthetic valve endocarditis, and ventricular tachycardia and cardiac arrest due to transmyocardial migration into the right ventricle and pulmonary artery [5–7].
The routine use of temporary epicardial pacing wires for open cardiac surgery has come under increased scrutiny. A recent study of 290 consecutive patients undergoing CABG at a major teaching hospital analyzed the incidence of pacing during the postoperative period and reported only 19 of 222 patients (8.6%) required pacing. Diabetes mellitus, preoperative arrhythmia, and pacing used to separate from bypass were significant predictors of postoperative pacing. Excluding patients with these risk factors, only 2.6% of patients required postoperative pacing [8].
In our case, the patient had preoperative ventricular fibrillation and was at increased risk for postoperative pacing, making him an appropriate candidate for temporary epicardial pacing wire placement intraoperatively. Unfortunately, the patient developed complications from retained epicardial pacing wires that were chronic, debilitating, and required repeat surgery to resolve.
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References
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- Del Nido P, Goldman BS. Temporary epicardial pacing after open heart surgery: complications and prevention J Card Surg 1989;4:99-103.[Medline]
- Carroll KC, Reeves LM, Andersen G, et al. Risks associated with removal of ventricular epicardial pacing wires after cardiac surgery Am J Crit Care 1998;7:444-449.[Abstract]
- Gal ThJ, Chaet MS, Novitzky D. Laceration of a spahenous vein graft by an epicardial pacemaker wire J Cardiovasc Surg 1998;39:221-222.[Medline]
- Bolton JW, Mayer Jr JE. Unusual complication of temporary pacing wires in children Ann Thorac Surg 1992;54:769-770.[Abstract]
- Gentry WH, Hassan AA. Complications of retained epicardial pacing wires: an unusual bronchial foreign body Ann Thorac Surg 1993;56:1391-1393.[Abstract]
- Mansur AJ, Grinberg M, Costa R, Ven Chung C, Pileggi F. Dura mater valve endocarditis related to retained fragment of postoperative temporary epicardial pacemaker lead Am Heart J 1984;108:1049-1052.[Medline]
- Meier DJ, Tamirisa KP, Eitzman DT. Ventricular tachycardia associated with transmyocardial migration of an epicardial pacing wire Ann Thorac Surg 2004;77:1077-1079.[Abstract/Free Full Text]
- Bethea BT, Salazar JD, Grega MA, et al. Determining the utility of temporary pacing wires after coronary artery bypass surgery Ann Thorac Surg 2005;79:104-107.[Abstract/Free Full Text]
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Abstract
Introduction
