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Unusual complications of endocardial pacing
Insights
Endocardial pacing leads can cause rare but serious complications like vena cava thrombosis and tricuspid valve stenosis. Removing retained leads is recommended due to high rates of subclinical venous thrombosis.
Area of Science:
- Cardiology
- Medical Devices
- Vascular Surgery
Background:
- Endocardial pacing is a common treatment for cardiac rhythm disorders.
- Complications associated with indwelling pacing leads are a significant concern.
- Unusual complications necessitate a review of current practices and lead management.
Observation:
- Two patients experienced severe complications: simultaneous superior and inferior vena cavae thrombosis and extensive tricuspid valve stenosis.
- Management involved complex procedures including cardiopulmonary bypass, lead removal, vena cava thrombectomy, and tricuspid valve replacement.
- Literature review revealed clinical thrombosis in 1.2% of cases, but venography showed asymptomatic venous thrombosis in 44% of patients.
Findings:
- Endocardial pacing leads, especially those with large diameters or implanted with redundancy, increase the risk of venous thrombosis.
- Atrioventricular sequential pacing systems requiring multiple leads through the superior vena cava pose a higher risk.
- Retained, infected, or migrated leads are associated with septicemia, thrombosis, and embolization.
Implications:
- Minimizing lead diameter and utilizing thromboresistant materials are crucial for preventing complications.
- Systematic removal of retained leads, even in asymptomatic individuals, is suggested due to high subclinical thrombosis rates.
- Careful consideration of lead placement and system complexity is necessary to mitigate risks associated with endocardial pacing.
Abstract:
This report concerns two unusual complications of endocardial pacing: (1) simultaneous thrombosis of the superior and inferior venae cavae and (2) supravalvular, valvular, and infravalvular stenosis of the tricuspid valve. The management of both cases required removal of all endocardial leads with the aid of cardiopulmonary bypass, with inferior vena cava thrombectomy in the first case and tricuspid valve replacement in the second. From our review of the literature, we have reached the following conclusions: (1) Clinical thrombosis secondary to endocardial pacing leads is rare (1.2%), but venography in asymptomatic patients revealed venous thrombosis in 44% of the patients studied. (2) Endocardial pacing leads should have the smallest outer diameter possible, preferably with an electro-negative, thromboresistant surface, and should be implanted with minimal redundancy. The risk of venous thrombosis should be kept in mind when recommending atrioventricular sequential pacing systems requiring multiple leads passing through the superior vena cava. (3) Retained leads which are infected or have migrated and become redundant or looped are at risk of causing septicemia, thrombosis, or septic embolization and should be removed. The high incidence of subclinical venous thrombosis suggests that reasonable efforts be made to remove all retained leads.