Ann Thorac Surg 2009;87:942-943. doi:10.1016/j.athoracsur.2008.07.049
© 2009 The Society of Thoracic Surgeons
Case Reports
Epicardial Pacemaker Lead-Induced Ventricular Tachycardia
Jae Gun Kwak, MDa,
Woong-Han Kim, MD, PhDb,*,
Eun Jung Bae, MDc
a Department of Thoracic and Cardiovascular Surgery, Sejong Heart Institution, Sejong General Hospital, Bucheon, Gyeonggi-Do, Korea
b Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
c Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
Accepted for publication July 11, 2008.
* Address correspondence to Dr Woong-Han Kim, Department of Thoracic and Cardiovascular Surgery, Seoul National University, College of Medicine, Seoul National University Children's Hospital, 28 Yongon-Dong, Jongno-Gu, Seoul, 110-744, Korea (Email: woonghan{at}snu.ac.kr).
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Abstract
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A 9-year-old boy with a permanent epicardial screw-type ventricular pacemaker lead (VVI mode), fitted due to a complete atrioventricular block after ventricular septal defect closure at 5 months of age, showed ventricular tachycardia during maximal exercise testing. The pacemaker lead was found to have fractured at 30 mm from the tip, and the screw tip penetrated the right ventricular cavity. Pace mapping at the anterior free wall of the right ventricle detected a 12/12 matched ventricular tachycardia focus around the site of penetration. The fractured lead was extracted under cardiopulmonary bypass support and the lead insertion site cryoablated. Subsequently, ventricular tachycardia was not induced during maximal exercise testing.
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Introduction
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The safety and efficacy of epicardial permanent pacemaker leads are generally accepted, but complications can occur many years after placement. We describe a case involving the transmyocardial migration of a screw-type epicardial lead, such that the tip penetrated the right ventricle 8 years after implantation, which in the described case caused exercise-induced ventricular tachycardia.
A 9-year-old boy (26.4 kg) was transferred to our cardiovascular department for the surgical treatment of arrhythmia. When he was 5 months old, he underwent subarterial type ventricular septal defect patch closure through the main pulmonary artery. Immediately after surgery, he showed temporary arrhythmia, but normal sinus conversion was confirmed at 2 weeks postoperatively, and he was discharged. However, 1 month after hospital discharge he presented at the outpatient clinic with a complete atrioventricular block; he was treated by VVI type permanent pacemaker placement (with screw-type epicardial lead) at the right ventricular free wall, which resolved the problem.
However, at 8 years of age, he was referred to our institution. A chest roentgenogram indicated lead breakage (Fig 1A), although fortunately his heart rhythm was normal without any evidence of atrioventricular block. Echocardiography and computed tomography revealed that the lead tip had penetrated the right ventricular cavity and that this had resulted in the development of a mass-like lesion (Fig 1B). A small ventricular septal defect leakage was also evident. After a year of observation, a pediatrician decided to perform an exercise test to evaluate his functional status, and it was found during maximal exercise that ventricular tachycardia (VT) with a heart rate of 170/min was reproducibly induced (Fig 2). Holter monitoring revealed no heart block event, but occasional premature ventricular contractions. Furthermore, an invasive electrophysiological study revealed that sustained VT was not induced by right ventricular pacing. However, pace mapping at the anterior free wall of the right ventricle demonstrated a 12/12 matched VT focus around the previous pacemaker lead insertion site. A surgical approach was considered to correct these lesions.
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Fig 1. Preoperative images. (A) Chest roentgenogram showing a fractured screw-type pacemaker lead tip penetrating the right ventricular cavity. (B) Computed tomographic view, in which the intruded epicardial lead is indicated by an arrow.
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Fig 2. Ventricular tachycardia with QRS complex and left bundle branch block morphology was induced during treadmill exercise testing.
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Under conventional cardiopulmonary bypass and aortic cross clamping, the ventricular lead fixed at the right ventricular free wall was retracted. The screw-type pacemaker lead had fractured at 30 mm from its tip, and the lead tip, still wrapped by intact insulating peel, had then penetrated the right ventricular cavity. The remained part of the lead was fixed at the sternum. After removing the pacemaker lead and the mass lesion that had formed around it, the fibrotic area where the ventricular lead was fixed was cryoablated. This was followed by pulmonary arteriotomy, closure of the residual ventricular septal defect, and removal of the pacemaker generator located in the rectus fascia. The operation was uneventful. Furthermore, Holter monitoring and exercise testing performed at 2 months postoperatively failed to induce any evidence of arrhythmia. At his last follow-up (5 months postoperatively), an electrocardiogram demonstrated a normal sinus rhythm.
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Comment
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Several reports have addressed complications associated with permanent or temporary pacemaker leads. The major concern of cardiac chamber perforation is associated with lead migration [1, 2], which can induce cardiac tamponade, hemoptysis, or migration into the peritoneal cavity, or more rarely may result in an intermittent twitching pain in the left subcostal area [2]. Arrhythmia can also be induced by pacemaker leads or temporary pacing wires. Carroll and colleagues [3] reported that 7% of their patients experienced nonsustained ventricular tachycardia during temporary pacemaker wire removal, and that 66% of their patients experienced at least one premature ventricular contraction during the removal procedure [3]. Meier and colleagues [4] reported a case of ventricular pacemaker lead migration into the pulmonary artery through the right atrium and right ventricle, which caused ventricular tachycardia and cardiac arrest. In most of previously described cases, the key to definitive treatment was pacemaker lead extraction, and Casella and colleagues [5] reported the additional treatment, such as a delivery of radiofrequency pulses for lead-induced right ventricular tachycardia.
In our case, an epicardial screw-type ventricular lead tip had penetrated deeply into the right ventricle, probably 8 years previously, and as a result, myocardium in this area had formed an intracardiac mass composed of thick and fibrotic tissue around the lead tip. Before the operation, it was confirmed by electrophysiologic studies that this area constituted the automatic focus for the ventricular tachycardia. Pace mapping at the right ventricle around the pacemaker lead tip was matched to a 12-lead QRS of ventricular tachycardia, and the damaged myocardium was presumed to be the substrate for ventricular tachycardia. In addition, this scar area was cryoablated after lead extraction.
The present case raises concerns about optimal ventricular pacemaker lead location. In our opinion, the right ventricular diaphragmatic area is a better proposition than the free wall. As was demonstrated by the present case, if a lead becomes fixed to the sternum due to fibrotic change, there is a greater likelihood of it penetrating the right ventricle.
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References
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- Akyol A, Aydin A, Erdinler I, Oguz E. Late perforation of the heart, pericardium and diaphragm by an active-fixation ventricular lead Pacing Clin Electrophysiol 2005;28:350-351.[Medline]
- Ramirez MF, Ching CK, Ho KL, Teo WS. "The attack of the 52cm lead"—an unusual case of late cardiac perforation by a passive-fixation permanent pacemaker lead Int J Cardiol 2007;115:e5-e7.[Medline]
- Carroll KC, Reeves LM, Andersen G, et al. Risks associated with removal of ventricular epicardial pacing wires after cardiac surgery Am J Cirt Care 1998;7:444-449.
- 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]
- Casella M, Dello Russo A, Pelargonio G, Tondo C. Sustained right ventricular tachycardia originating close to defibrillator lead tip in hypertrophic cardiomyopathy J Cardiovasc Electrophysiol 2007;18:994-997.[Medline]
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Abstract
Introduction
