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Left heart pacing and cardioembolic stroke
M Sharifi1, R Sorkin, J B Lakier
1Department of Medicine, Lutheran General Hospital, Park Ridge, Illinois 60068.
Insights
Pacemaker leads in the left heart can cause stroke. Prompt anticoagulation is crucial, as aspirin alone is insufficient for protection against these embolic stroke events.
Area of Science:
- Cardiology
- Neurology
- Medical Device Technology
Background:
- Pacemaker lead placement is a common cardiovascular procedure.
- Inadvertent malpositioning of leads can lead to serious complications.
- Neurological symptoms like embolic stroke are a potential risk.
Observation:
- Three patients presented with neurological deficits suggestive of embolic stroke.
- Pacemaker leads were found to be inadvertently positioned within the left heart chambers or major arteries.
- Specific malpositions included crossing the interatrial septum, mitral valve, aortic valve, and entering the left ventricle.
Findings:
- Symptoms resolved with the initiation of anticoagulation therapy.
- Recurrence of symptoms and a major stroke occurred when anticoagulation levels decreased.
- Two patients were on aspirin, indicating antiplatelet therapy alone was inadequate.
Implications:
- Malpositioned pacemaker leads pose a significant risk for embolic stroke.
- Complete removal of the malpositioned lead should be strongly considered.
- Full-dose anticoagulation is necessary for stroke prevention in these cases, exceeding the protection offered by antiplatelet therapy alone.
Abstract:
Three patients with inadvertently positioned left heart pacemaker leads were admitted for neurological symptoms consistent with embolic stroke. In one of them, the pacemaker lead crossed the interatrial septum, the mitral valve, and entered the left ventricle. In another it was erroneously placed through the subclavian artery, across the aortic valve, and into the left ventricular chamber. In the third patient, the right ventricular lead of a DDD pacemaker was placed in the coronary sinus and the right atrial lead crossed the interatrial septum, and intermittently entered the left ventricular cavity. Once anticoagulation was initiated, symptoms resolved; they recurred when the level of anticoagulation dropped leading to a major stroke in one of the patients. Two of the patients were on aspirin at the onset of symptoms. We believe that every approach must be considered to remove the malpositioned lead. Otherwise, full dose anticoagulation must be initiated since antiplatelet therapy alone does not confer adequate protection against stroke.