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Successful percutaneous extraction of an inadvertently placed left ventricular pacing lead
C C de Cock1, C M C van Campen, O Kamp
1VU University Medical Center, Department of Cardiology 6 D 120, PO Box 7057, 1007 MB Amsterdam, The Netherlands.
Insights
This study presents a case of a patient with a pacemaker lead traversing an atrial septal defect. Percutaneous lead extraction using a locking device was successfully performed, avoiding complications.
Area of Science:
- Cardiology
- Medical Devices
- Interventional Cardiology
Background:
- A 74-year-old patient with hypertension, diabetes, and a history of transient ischemic attack presented with a rising pacing threshold 9 months post-implantation of a dual-chamber pacemaker (DDD) for symptomatic atrioventricular block.
- Standard pacemaker lead placement involves the right atrium and ventricle; however, this patient's lead was found to be in an unusual position.
Observation:
- 3-dimensional transesophageal echocardiography revealed the pacemaker lead coursing through an atrial septal defect into the left ventricle.
- The patient had multiple risk factors for stroke, including hypertension, diabetes with micro-angiopathy, and a recent transient ischemic attack.
- No thrombus was detected on the lead itself.
Findings:
- Percutaneous lead extraction using a locking device was chosen over surgical extraction with cardiopulmonary bypass due to the patient's high risk of stroke.
- The percutaneous extraction was performed without complications.
Implications:
- This case highlights a rare complication of pacemaker implantation where the lead traverses an atrial septal defect.
- Percutaneous lead extraction with a locking device can be a safe and effective alternative in high-risk patients when traditional methods pose significant risks.
- Successful extraction in this complex scenario suggests the utility of advanced extraction techniques for managing malpositioned pacemaker leads.
Abstract:
A 74-year-old patient was referred for a rapidly increasing pacing threshold 9 months after DDD pacemaker implantation because of symptomatic total atrioventricular (AV) block. She had a history of hypertension, diabetes with micro-angiopathy and a recent transient ischaemic attack. The paced electrocardiogram on admission had a right bundle branch block pattern and 3-dimensional transoesophageal echocardiography demonstrated passage of the lead through an atrial septal defect with a left ventricular position in addition to moderate atherosclerosis of the ascending aorta. No thrombus could be detected on the lead. Percutaneous extraction is usually not recommended because of the risk of mobilization of thrombus material. However, the risk of stroke during removal using cardiopulmonary bypass in this patient was considerably increased because of the presence of multiple independent risk factors. Therefore, percutaneous extraction using a locking device was selected and performed without complications: follow-up was uneventful.