Pacemaker lead failure due to crush injury / Ezilme hasarina bagli kalici kalp pili elektrod kusuru.

Introduction

Different techniques for pacemaker implantation such as subclavian, cephalic and transiliac vein are being used today for various circumstances (1, 2). One of the potential complications of pacemaker implantation is the lead fracture or insulation failure due to crush injury. It usually occurs after medial intrathoracic puncture of the subclavian vein and results in damaging of the pacemaker lead body by entrapment within the costoclavicular ligament and/or the subclavian muscle (3, 4). The present case report describes a patient who underwent pacemaker implantation seven years ago and developed lead failure due to crush injury detected by chest X-ray and telemetry data.

Case report

A 33-year-old woman with a history of sick sinus syndrome underwent a dual chamber pacemaker implantation (Ela DR213 Talent, Ela 4068 for atrial, and BT46D for ventricular leads) seven years ago. Because of battery depletion the pulse generator was replaced with a Guidant 1296 generator. Pacing threshold, R wave and impedance of ventricular lead during implant were 0.7 V at 0.5 msec, 7 mV and 350 ohms, respectively. Pacing threshold, R wave and impedance of atrial lead were 1.2 V at 0.5 msec, 3 mV and 650 ohms, respectively. During follow-up telemetry data revealed intermittent sensing and pacing problem with the atrial lead. Measured impedance values were changing day by day between 540 and 1320 ohms, as shown in Table 1. Intermittent major changes in impedance values were suggestive of a lead malfunction, namely fracture that might be related to crush injury. The intracardiac electrocardiogram recordings revealed multiple artifacts and noise in the atrial channel (Fig. 1). A chest X-ray showed partial thinning and damage to the atrial lead body right at the medial puncture site of the subclavian vein (Fig. 2). All of these findings together with sensing failure probably reflected a partial fracture in the lead body, which was not detected during the implant. Since the patient had good intrinsic sinus rhythm at a rate of 55 bpm and potential complication risk during a subsequent lead revision, which was also refused by the patient, we reprogrammed the generator to VVIR mode that was well tolerated by the patient during follow-up.

Discussion

Subclavian vein puncture is commonly performed to insert the lead for permanent pacemakers and implantable defibrillators. Intrathoracic subclavian vein approach is performed in more than 65% of all endocardial leads (5). However, this medial puncture technique is potentially responsible for increased risk of lead fracture, pneumothorax and hemothorax (6). Lead fracture occurs in approximately 1-4% of permanent pacing systems whereas its incidence in transvenous cardioverter defibrillator systems is not well established (7). Subclavian crush syndrome is a well-known cause of pacemaker lead failure, namely conductor fractures and insulation failure by compression of the lead between the first rib and the clavicle (8). Besides cephalic vein cut-down technique, extrathoracic axillary vein puncture is currently suggested as an alternative technique for venous access to avoid crush injury. This novel technique may also be performed by giving some contrast agent through the ipsilateral brachial vein for guidance (5). Furthermore, ultrasound guidance for subclavian vein puncture may also be useful and effective for pacing lead insertion (10). Belott (11), comprehensively described how to safely perform this technique, in a recently published review. Axillary vein can be accessed blindly through the incision with a needle puncture 1 or 2 cm medial and parallel to the deltopectoral groove at the level of the coracoid process. Furthermore, the first rib is a key fluoroscopic landmark. Use of the first rib for orientation is recommended to avoid pneumothorax. The first step in accessing the axillary vein using the first rib is to place the 18-gauge percutaneous needle and syringe on top of the pectoralis major muscle in the superior aspect of the incision. Using fluoroscopy, the needle tip is placed in the middle of the first rib (Fig. 3). The angle of the syringe and needle is gradually increased as the needle is advanced through the pectoralis major muscle. Needle advancement is continued until the first rib is struck. Once the first rib is touched, the needle and syringe are slowly withdrawn under suction until the vein is entered. Once the vein is entered, the guidewire is passed and the sheath applied per standard technique. If axillary vein cannot be found by this technique, the use of radiographic contrast or ultrasound to visualize the axillary vein is recommended (11). As previously proposed by other authors (5,11), we also recommend the extrathoracic subclavian or axillary vein approach for implantation of pacemaker leads and suggest that the classic intrathoracic subclavian approach should be abandoned. Telemetric evaluation during follow-up should always be performed in order to determine the measured data such as impedance and thresholds. Since detection of lead failure may be intermittent, it may be overlooked during pacemaker follow-up. When the lead impedance is measured below 200 ohms, one may suspect of an insulation failure; whereas an impedance measured more than 1000 ohms is suggestive of lead fracture. Intracardiac electrocardiograms should also be checked for detection of noise. As it was shown in the present case, chest X-ray may reveal damage to the lead body right at the sternoclavicular region and intracardiac electrocardiographic detection of noise should not be neglected.

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Conclusion

In conclusion, we propose to perform extrathoracic subclavian or axillary vein approach for implantation of pacemaker leads and always check the lead status by telemetry during follow-up.

References

(1.) Belott PH. Implant techniques. In: Kusumato FM, Goldschlager NF, editors. Cardiac Pacing for the Clinician. Philadelphia: Lippincott Williams and Wilkins, 2001: p, 91-162.

(2.) Erdogan O, Augostini R, Saliba W, Juratli N, Wilkoff BL. Transiliac permanent pacemaker implantation after extraction of infected pectoral pacemaker systems. Am J Cardiol 1999; 84: 474-5.

(3.) Altun A, Erdogan O. Pacemaker lead failure suggestive of crush injury. Cardiol Rev 2003; 11: 256.

(4.) Suzuki Y, Fujimori S, Sakai M, Ohkawa S, Ueda K. A case of pacemaker lead fracture associated with thoracic outlet syndrome. Pacing Clin Electrophysiol 1988; 11: 326-30.

(5.) Ramza BM, Rosenthal L, Hui R, Nsah E, Savader S, Lawrence JH, et al. Safety and effectiveness of placement of pacemaker and defibrillator leads in the axillary vein guided by contrast venography. Am J Cardiol 1997; 80: 892-6.

(6.) Chauhan A, Grace AA, Newell SA, Stone DL, Shapiro LM, Schofield PM, et al. Early complications after dual chamber versus single chamber pacemaker implantation. Pacing Clin Electrophysiol 1994; 17: 2012-5.

(7.) Gallik DM, Ben-Zur UM, Gross JN, Furman S. Lead fracture in cephalic versus subclavian approach with transvenous implantable cardioverter defibrillator systems. Pacing Clin Electrophysiol 1996; 19: 1089-94.

(8.) Magney JE, Flynn DM, Parsons JA, Staplin DH, Chin-Purcell MV, Milstein S, et al. Anatomical mechanisms explaining damage to pacemaker leads, defibrillator leads, and failure of central venous catheters adjacent to the sternoclavicular joint. Pacing Clin Electrophysiol 1993; 16: 445-57.

(9.) Burri H, Sunthorn H, Dorsaz PA, Shah D. Prospective study of axillary vein puncture with or without contrast venography for pacemaker and defibrillator lead implantation. Pacing Clin Electrophysiol 2005; 28: 280-3.

(10.) Orihashi K, Imai K, Sato K, Hamamoto M, Okada K, Sueda T. Extrathoracic subclavian venipuncture under ultrasound guidance. Circ J 2005; 69: 1111-5.

(11.) Belott P. How to access the axillary vein. Heart Rhythm 2006; 3: 366-9.

Okan Erdogan, Meryem Aktoz

Department of Cardiology, School of Medicine, Trakya University, Edirne, Turkey

Address for Correspondence/Yazisma Adresi: Okan Erdogan, MD, Arseven Sitesi Villa Konutlari No:2 D-100 Karayolu 22030 Edirne, Turkey Phone: [phone] E-mail: [e-mail]

Table 1. Stored data of atrial lead impedance measured automatically
at various intervals through the generator

Date               Impedance, Ohm

29 May 2005             1070
28 May 2005              600
27 May 2005             1070
26 May 2005              540
25 May 2005              540
24 May 2005             1320
23 May 2005              580
18 May 2005              650
11 May 2005              910
04 May 2005              790
27 Apr 2005              640
20 Apr 2005              550