European Journal of Echocardiography Advance Access published online on June 19, 2008
European Journal of Echocardiography, doi:10.1093/ejechocard/jen187
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Eight years of left ventricle pacing due to inadvertent malposition of a transvenous pacemaker lead in the left ventricle
Daniel Vanhercke*,
Wendy Heytens and
Hugues Verloove
Department of Cardiology, AZ Sint Lucas, Groenebriel 1, BE9000 Gent, Belgium
Received 13 April 2008; accepted after revision 25 May 2008.
* Corresponding author. Tel: +32 9 224 6401; fax: +32 9 224 6409. E-mail address: daniel.vanhercke{at}azstlucas.be
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Abstract
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The inadvertent malposition of a pacemaker lead in the left
ventricle is a rare and underdiagnosed pacemaker complication.
A 78-year-old woman was admitted to our Emergency Department
for progressive dyspnea, 8 years after transvenous pacemaker
implantation. Routine 12-lead electrocardiography revealed a
right bundle branch block on the paced beats, and lateral chest
X-ray showed posterior deflection of the pacemaker lead, suggesting
a pacemaker electrode in the left ventricle. Echocardiography
confirmed that the pacing lead had migrated through the foramen
ovale into the left ventricle. After review of the literature
and taking into account the age and emboligenic-free history
of the patient under platelet therapy, we decided to postpone
the surgical removal of the malpositioned lead in the left ventricle
until the need arose for cardiac surgery for additional reasons,
such as valve and/or coronary illness. The general therapeutic
strategy remained unchanged due to the risk of bleeding complications
with anticoagulation in the patient. This case illustrates the
prominent role of echocardiography in the diagnosis of unusual
cardiac events.
Keywords: Left ventricle; Pacemaker; Malpositioned pacemaker lead
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Introduction
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Malposition of pacemaker leads in several locations is described
in the literature, but rarely in the left ventricle. The incidence
and clinical history of this type of pacemaker complication
is under-reported and not well known.
We report the clinical, electrographical, chest X-ray, and echocardiographic findings of a 78-year-old female patient in whom the intravenous lead inadvertently migrated through the foramen ovale at the time of implantation, becoming fixed in the lateral part of the left ventricle after passage through the mitral valve. Malposition of the lead was diagnosed 8 years after the implantation procedure. The patient was on antiplatelet therapy for atrial fibrillation and had no signs of emboligenic history; echocardiography found no evidence of thrombus on the pacemaker electrode. Pacing thresholds were normal at the time of implantation and were documented as being normal during follow-up.
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Case report
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A 78-year-old female patient was admitted to our Emergency Department
for progressive dyspnea of 3 weeks duration. She had a
past history of brady–tachy syndrome with VVI pacemaker
implantation in 1999, a long-term history of atrial fibrillation
treated with beta-blockers and digoxin, and a known hypothyroidism
treated with levothyroxine. Blood pressure was 148/82 mmHg.
Electrocardiogram (Figure 1) showed a right bundle branch block pattern during VVI pacing, and chest X-ray (Figure 2) showed cardiomegaly with a posterior deflection of the VVI pacemaker electrode on the lateral view. Transthoracic echocardiogram (Figure 3) with colour flow mapping and Doppler analysis in the normal parasternal and apical windows showed a slightly enlarged left atrium and normal diameter of the left ventricle, with an ejection fraction of 52% and a moderate leak of the mitral and tricuspid valves. Because the trace of the pacemaker lead could not be followed, alternative echo windows were used on the lower intercostals, revealing an abnormal route of the migrated pacemaker lead: from the right atrium, the lead passed through the foramen ovale, left atrium, and mitral valve, with fixation of the pacemaker electrode in the mid-lateral part of the left ventricle. There were no signs of thrombus formation on the pacemaker lead. The mitral valve appeared to have good function, with no damage to the valve leaflets.
After reviewing the literature, we decided to postpone surgical
removal of the malpositioned lead in the left ventricle until
cardiac surgery became necessary for additional reasons, such
as valve and/or coronary illness, because of the age and the
non-emboligenic history of the patient and because she was receiving
antiplatelet therapy. The general therapeutic strategy remained
unchanged due to the risk of bleeding complications with anticoagulation
in the patient.
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Discussion
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Despite improving knowledge and growing expertise in pacemaker
implantation procedures, complications remain a problem that
should not be underestimated.
1,2 Large follow-up studies show
a mean overall complication rate in pacemaker implantation of
3.4–5.7%.
3
The expected morphology of right ventricular pacing is a left bundle branch block; however, right bundle branch block can be seen during permanent right ventricular pacing. In a cohort of 300 consecutive patients, Okmen et al.4 found that 8.3% exhibited right bundle branch block in ‘true right ventricular pacing’, which fell to 4.3% after modifying the electrocardiogram locations to one interspace lower than the standard locations (Klein manoeuvre).4
If right bundle branch block of paced beats is present, chest X-ray including a lateral view should be obtained to assess the position of the pacemaker lead. X-ray may clarify that the pacemaker electrode is not positioned in the right ventricular apex, but is sometimes insufficient because left ventricular position can easily be mistaken for coronary vein position.5 Therefore, echocardiography is necessary to remove any doubt.
Anticoagulation should be considered when this problem comes to attention for the first time during follow-up. Lifetime anticoagulation therapy or surgical retraction should be considered because patients with left ventricular lead positioning have significant risk of embolization from thrombus formation on the lead.6
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Conclusion
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Diagnosis of left ventricular lead malposition is not difficult,
but requires a high index of suspicion. Care should be taken
to recognize this potentially serious complication that may
occur even in the most trained and experienced hands.
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References
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- Kazama S, Nishiyama K, Machii M, Tanaka K, Amano T, Nomura T, et al. Long-term follow up of ventricular endocardial pacing leads. Complications, electrical performance, and longevity of 561 right ventricular leads. Jpn Heart J (1993) 34:193–200.[Medline]
- Van Gelder BM, Bracke FA, Oto A, Yildirir A, Haas PC, Seger JJ, et al. 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) 23:877–83.[CrossRef][Medline]
- Parsonnet V, Bernstein AD, Lindsay B. Pacemaker-implantation complication rates: an analysis of some contributing factors. J Am Coll Cardiol (1989) 13:917–21.[Abstract]
- Okmen E, Erdinler I, Oguz E, Akyol A, Turek O, Cam N, et al. An electrocardiographic algorithm for determining the location of pacemaker electrode in patients with right bundle branch block configuration during permanent ventricular pacing. Angiology (2006) 57:623–30.[Abstract/Free Full Text]
- Engström A, Holmberg B, Mansson A, Carlsson J. Inadvertent malposition of a transvenous pacing lead in the left ventricle. Herzschrittmacherther Elektrophysiol (2006) 17:221–4.[CrossRef][Medline]
- Paravolidakis KE, Hamodraka ES, Kolettis TM, Psychari SN, Apostolou TS. Management of inadvertent left ventricular permanent pacing. J Interv Card Electrophysiol (2004) 10:237–40.[CrossRef][Web of Science][Medline]
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Abstract
Introduction
