【medical-news】【资讯翻译】心房螺旋电极穿孔导致急性心包填塞
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Europace ：病例分析
Acute pericardial tamponade due to screw-in atrial lead heart perforation
A 74-year-old man presented with symptomatic bradycardia because of sick sinus syndrome. A dual-chamber pacemaker was implanted with Medtronic screw-in atrial (model 5076-52) and ventricular (model 5076-58) leads.
The atrial lead was screwed in the anterior atrial wall and the ventricular lead in the interventricular septum by rotating the connector pin up to 10 turns; normal sensing and pacing parameters were achieved and post-implantation stable lead position was confirmed by fluoroscopy (Figure 1A, B). Temporary stimulation at 10 V output did not show any extra cardiac stimulation.
Shortly after the procedure the patient complained of vague chest discomfort; blood pressure was 140/80 mmHg. Two hours later he started to complain of chest pain, especially during deep inspiration, but blood pressure remained stable. A transthoracic echocardiogram revealed mild tomoderate pericardial effusion without signs of tamponade. Four hours after the implantation the patient became hypotensive; a repeated echocardiogram revealed a large pericardial effusion and evidence of tamponade (Figure 1C). The patient was referred to a hospital with a thoracic surgical backup. Immediately after arrival, because of profound shock, a median sternotomy was preferred over pericardiocentesis, with drainage of a large amount of unclotted blood; a 1 mm tear was found on the anterior wall with active bleeding where the tip of the atrial lead helix was protruding. The atrial lead was removed and, because of ongoing bleeding, the tear was sutured. A new atrial lead was not implanted at that time. The patient recovered uneventfully; at 3-month follow-up the patient was asymptomatic.
Discussion
Pericardial tamponade due to cardiac perforation is the most serious and life-threatening complication following pacemaker implantation.
In case of delayed pericardial tamponade (>30 days after device implantation), some authors2advice drainage of the effusion followed by a conservative strategy.
In acute cardiac tamponade prompt pericardiocentesis and lead reposition are the therapies of choice;3however, in rare cases characterized by rapid clinical and haemodynamic deterioration, like ours, urgent surgical intervention with lead extraction/reposition is warranted for treatment.
Unlike ventricular perforations that may seal after the lead retraction, the atrial ones may not, because of the thin atrial wall and require open drainage; closed pericardiocentesis is rarely successful (<25%).1
Overscrewing of the lead and distal stylet insertion are mechanisms that are associated with atrial wall perforation. In our patient, overscrewing was unlikely due to the measured number of turns under fluoroscopic control. Perhaps an excessive pressure exerted through the lead with a distally inserted stylet may have caused the penetration of the helix through the atrial wall.
Active fixation atrial leads have advantages and disadvantages: they allow more choices for lead placement, but the implanter has to be aware of the risks, although rare, of pericarditis and heart perforation when choosing them.
Figure 1 (A) The fluoroscopy (LAO view) shows the atrial and ventricular leads position at the end of the implantation. (B) The fluoroscopy (RAO view) shows the closed space (arrows) between the markers of the leads implying complete exposure of the helix. (C) Transthoracic echocardiogram subcostal view showing the helix of the atrial lead perforating the right atrial wall (in the circle), the ventricular lead (1) positioned in the interventricular septum, and the pericardial effusion (2).
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翻译时参照版规http://news.dxy.cn/bbs/topic/8600034
Europace ：病例分析
Acute pericardial tamponade due to screw-in atrial lead heart perforation
A 74-year-old man presented with symptomatic bradycardia because of sick sinus syndrome. A dual-chamber pacemaker was implanted with Medtronic screw-in atrial (model 5076-52) and ventricular (model 5076-58) leads.
The atrial lead was screwed in the anterior atrial wall and the ventricular lead in the interventricular septum by rotating the connector pin up to 10 turns; normal sensing and pacing parameters were achieved and post-implantation stable lead position was confirmed by fluoroscopy (Figure 1A, B). Temporary stimulation at 10 V output did not show any extra cardiac stimulation.
Shortly after the procedure the patient complained of vague chest discomfort; blood pressure was 140/80 mmHg. Two hours later he started to complain of chest pain, especially during deep inspiration, but blood pressure remained stable. A transthoracic echocardiogram revealed mild tomoderate pericardial effusion without signs of tamponade. Four hours after the implantation the patient became hypotensive; a repeated echocardiogram revealed a large pericardial effusion and evidence of tamponade (Figure 1C). The patient was referred to a hospital with a thoracic surgical backup. Immediately after arrival, because of profound shock, a median sternotomy was preferred over pericardiocentesis, with drainage of a large amount of unclotted blood; a 1 mm tear was found on the anterior wall with active bleeding where the tip of the atrial lead helix was protruding. The atrial lead was removed and, because of ongoing bleeding, the tear was sutured. A new atrial lead was not implanted at that time. The patient recovered uneventfully; at 3-month follow-up the patient was asymptomatic.
Discussion
Pericardial tamponade due to cardiac perforation is the most serious and life-threatening complication following pacemaker implantation.
In case of delayed pericardial tamponade (>30 days after device implantation), some authors2advice drainage of the effusion followed by a conservative strategy.
In acute cardiac tamponade prompt pericardiocentesis and lead reposition are the therapies of choice;3however, in rare cases characterized by rapid clinical and haemodynamic deterioration, like ours, urgent surgical intervention with lead extraction/reposition is warranted for treatment.
Unlike ventricular perforations that may seal after the lead retraction, the atrial ones may not, because of the thin atrial wall and require open drainage; closed pericardiocentesis is rarely successful (<25%).1
Overscrewing of the lead and distal stylet insertion are mechanisms that are associated with atrial wall perforation. In our patient, overscrewing was unlikely due to the measured number of turns under fluoroscopic control. Perhaps an excessive pressure exerted through the lead with a distally inserted stylet may have caused the penetration of the helix through the atrial wall.
Active fixation atrial leads have advantages and disadvantages: they allow more choices for lead placement, but the implanter has to be aware of the risks, although rare, of pericarditis and heart perforation when choosing them.
Figure 1 (A) The fluoroscopy (LAO view) shows the atrial and ventricular leads position at the end of the implantation. (B) The fluoroscopy (RAO view) shows the closed space (arrows) between the markers of the leads implying complete exposure of the helix. (C) Transthoracic echocardiogram subcostal view showing the helix of the atrial lead perforating the right atrial wall (in the circle), the ventricular lead (1) positioned in the interventricular septum, and the pericardial effusion (2).
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