ARTICLE IN PRESS doi:10.1510/icvts.2008.190793
Interactive CardioVascular and Thoracic Surgery 8 (2009) 235–237 www.icvts.org
Negative results - Congenital
Malpositioning of a pacemaker lead to the left ventricle accompanied by posterior mitral leaflet injury Hiroshi Sekia,*, Toshihiro Fukuia, Tomoki Shimokawaa, Susumu Manabea, Yoshiyuki Watanabea, Kimiaki Chinob, Shuichiro Takanashia Department of Cardiovascular Surgery, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu City, Tokyo 183-0003, Japan b Department of Cardiovascular Medicine, Sasa General Hospital, Tokyo, Japan
a
Received 26 August 2008; received in revised form 29 October 2008; accepted 3 November 2008
Abstract There have been several reports of a malpositioned pacemaker lead as a complication in pacemaker implantation. Herein we report a rare case of a malpositioned pacemaker lead in the left ventricle, which could occur in patients with cardiac structural abnormalities. A 70-year-old woman, who had undergone implantation of a pacemaker at the left subclavian position for complete atrioventricular block five years previously, was evaluated because of dyspnea and low grade fever. Echocardiography revealed a congenital atrial septal defect through which the lead was placed into the left ventricle. Whereas percuteneous lead removal seemed to be full of risk with concerns of thromboembolic events and infective endocarditis, the patient was referred to our hospital for surgical removal of the wire and closure of the defect. The lead was a screw-in type and removed and was extracted in the theatre using radiography. Intraoperatively it was found that the lead was positioned in the left ventricle apex after perforating the posterior mitral leaflet. Repair of the mitral valve perforation and closure of the septal defect and epicardial pacemaker lead implantation was performed. This case demonstrated the possibility of malposition of the pacemaker lead to the left ventricle in a transvenous pacemaker implantation procedure, which may lead to thromboembolic complication or infective endocarditis, and the pre-eminent role of echocardiography in the diagnosis of cardiac structural abnormalities. A malpositioned pacemaker lead in the left ventricle is a rare complication that can occur in patients with cardiac structural abnormalities. Lateral chest roentgenogram and echocardiography is efficient in preventing this complication. The removal of the lead in concerns of thromboembolic events and infection is preferable. 䊚 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Congenital heart disease; Pacemaker; Pacemaker complications; Mitral valve
1. Introduction A malpositioned pacemaker lead in the left ventricle is a rare complication, but can occur in patients with cardiac structural abnormalities. If detected, it needs to be removed because it could lead to damage of the mitral valve or a thromboembolic event. We report a case involving the successful repair of a pacemaker lead malpositioned in the left ventricle through a congenital atrial septal defect (ASD) after perforating the posterior mitral leaflet. 2. Case A 70-year-old woman, who had received a dual-chamber pacemaker for symptomatic complete atrioventricle block five years previously, was admitted to another hospital because of dyspnea with low grade fever. Chest roentgenogram (Fig. 1a,b) showed the pacing lead followed an unusual course. Transthoracic echocardiography revealed a secondum ASD with right ventricular dilatation. The ventricular pacing lead passed through the ASD and was posi*Corresponding author. Tel.: q81-42-314-3111; fax: q81-42-314-3133. E-mail address:
[email protected] (H. Seki). 䊚 2009 Published by European Association for Cardio-Thoracic Surgery
tioned in the apex of the left ventricle (Fig. 2a,b). Neither vegetation nor thrombus was detected around the lead by echocardiography. As well, no mitral valve regurgitation was detected. There was mild regurgitation of the tricuspid valve detected. Right catheterization showed that the pulmonary vein return was correct and QpyQs was 2.4. The pulmonary artery pressure was elevated to 41y21 mmHg and the wedge pressure was 20 mmHg. She had low grade fever, slightly high white blood cell count and a high level of C-reactive protein which marked 9.5 mgydl. With concerns of thromboembolic events and infective endocarditis, surgical removal was indicated. The patient was referred to our hospital for surgical removal of the malpositioned lead and closure of the ASD. The operation was performed under median sternotomy. Before the removal of the lead, it was screwed out under radiography, with a temporary epicardial pacemaker in use. Cardiopulmonary bypass was established with ascending aortic and bicaval venous cannulations. After aortic clamp and cardiac arrest, the right atrium was incised. The ASD was a congenital secondum type of 1=2 cm. An incision of the atrial septum extending the ASD was made to observe the left side of the heart. The lead was seen to go through the ASD to the left
ARTICLE IN PRESS 236
H. Seki et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 235–237
echocardiography performed before discharge showed no mitral regurgitation and no intracardiac residual shunt. There was no recurrence of high fever or C-reactive protein elevation suspecting infection during the postoperative course. 3. Discussion
Fig. 1. Chest roentgenogram showing the ventricular pacemaker lead directed toward the apex, but more posterior than the usual position. Front view (a). Lateral view (b).
Fig. 2. Transthoracic echocardiogram demonstrating the pacemaker lead implanted into the posterior wall of the left ventricle after passing through the interarterial septum. Parasternal long axis view (a). Apical 4-chamber view (b).
Fig. 3. Intraoperative photograph: The perforation of the posterior leaflet of the mitral valve made by the malpositioning of the pacemaker lead is observed.
ventricle after perforating the posterior mitral valve leaflet (Fig. 3). The perforation was repaired with a single stitch of 5-0 polypropylene after removal of the lead. The ASD was directly closed. Because thrombus with vegetation was found around the atrial lead, it was also removed. New epicardial pacemaker leads were then implanted. Vancomycin was administered postoperatively until both the culture and the DNA survey of the vegetation-like structure turned out to be negative of bacteria. The transthoracic
The malpositioning of a pacemaker lead is a rare complication in either temporary or permanent pacemaker implantation. Especially, a pacemaker lead inadvertently placed in the left ventricle is rare, with only a few cases reported w1–8x. The most common route for malpositioning to the left ventricle is through the interatrial septum, as in our case. A patent foramen ovale is the most probable cause of the malpositioning of the lead w2x, however, other possibilities reported include a sinus venosus atrial septal defect w3x and interventricular septum w4x. A malpositioned pacemaker lead can lead to several complications. First, systemic thromboembolic events can occur w5x. The actual incidence of thromboembolic events associated with leads in the left heart side has not been reported, but published cases in the literature suggest an incidence of about 37%. Our patient was fortunate not to have experienced any clinical thromboembolic events in the five years after the pacemaker implantation. Second, a lead may cause damage to the normal cardiac structure w6x, such as by a perforation of the mitral valve or the left ventricular wall. In our case, a perforation of the posterior leaflet of the mitral valve was observed. This could easily be repaired with a single stitch. However, an insufficiency of the mitral valve could occur by the malpositioned lead bending the leaflet. Finally, there is also some risk of infectious endocarditis of the left side of the heart w7x. This can lead to serious complications in the aortic and mitral valves. In the present case, our patient had an episode of unknown fever and preoperative elevated Creactive protein. Intraoperatively, we observed a vegetation-like structure around the lead. This alerted us to be concerned about infectious endocarditis. Treatment for a malpositioned lead into the left ventricle should be by surgical removal because, as we observed, there are several possible complications such as a perforation of the mitral leaflet and vegetation around the malpositioned lead. Although malpositioning of a pacemaker lead in the left ventricle is a rare complication, it can occur in patients with an undetected ASD. As there is the risk of thromboembolic events, damage to the left side of the heart or endocarditis, such a lead should be immediately replaced, when detected. References w1x Sharifi M, Sorkin R, Sharifi V, Lakier JB. Inadvertent malposition of a transvenous-inserted pacing lead in the left ventricular chamber. Am J Cardiol 1995;76:92–95. w2x Ananthasubramaniam K, Alam M, Karthikeyan V. Abnormal implantation of permanent pacemaker lead in the left ventricle via a patent foramen ovale: clinical and echocardiographic recognition of a rare complication. J Am Soc Echocardiogr 2001;14:231–233. w3x Van Erckelens F, Sigmund M, Lambertz H, Kreis A, Reupcke C, Hanrath P. Asymptomatic left ventricular malposition of a transvenous pacemak-
ARTICLE IN PRESS H. Seki et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 235–237 er lead through a sinus venous defect: follow-up over 17 years. Pacing Clin Electrophysiol 1991;14:989–993. w4x Stillman MT, MacDonell Richards A. Perforation of the interventricular septum by transvenous pacemaker catheter. Am J Cardiol 1969;24:269– 273. w5x Bo ¨hm A, Ba ´nyai F, Koma ´romy K, Pinte ´r A, Pre ´da I. Cerebral embolism due to a retained pacemaker lead: a case report. Pacing Clin Electrophysiol 1998;21:629–630. w6x Konings TC, Koolbergen DR, Bouma BJ, Groenink M, Mulder BJ. Iatrogenic perforation of the posterior mitral valve leaflet: a rare compli-
237
cation of pacemaker lead placement. J Am Soc Echocardiogr 2008;21: 512.e5–e7. w7x Schulze MR, Ostermaier R, Franke Y, Matschke K, Braun MU, Strasser RH. Aortic endocarditis caused by inadvertent left ventricular pacemaker lead placement. Circulation 2005;112:e361–e363. w8x Van Gelder BM, Bracke FA, Oto A, Yildirir A, Haas PC, Seger JJ, Stainback RF, Meijer A. Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: a multicenter experience and review of the literature. Pacing Clin Electrophysiol 2000;23:877–883.
