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  • In acute ventricular perforations the

    2019-05-31

    In acute ventricular perforations, the lead can be repositioned and followed with serial echocardiograms to monitor resolution of perforation and to detect deterioration that would require immediate intervention. In the subacute and delayed perforations, if there is no bleeding in the mediastinum, the lead can be left in place and another lead is placed in for use. If there is evidence of bleeding within or outside of the mediastinum, the lead must be extracted [11]. The active fixation leads can be removed transvenously under visualisation with trans-oesophageal echocardiogram [14]. The passive fixation leads have bulky tips that can cause damage with transvenous extraction. The recommended method of removal involves cardiothoracic surgery, cutting the tip and the lead body being removed transvenously [14]. The present case describes a patient with recent passive fixation lead perforation with no haemodynamic instability. This case shows the potential for ventricular perforation by the pacemaker passive fixation lead even after uneventful implantation. Our case is very unusual in the sense that the myocardial perforation occurred only after two weeks post-pacemaker protease activated receptor with passive fixation lead and we managed to take the lead out under local anaesthesia without involvement of the cardiothoracic surgeons, which was previously recommended [14]. This rare but serious complication can be appropriately managed by the clinical vigilance of the implanting cardiologist.
    Conflict of interest
    Authors׳ contributions
    Acknowledgements The authors appreciate the support of the Catheterisation Laboratory Staff, Southend University Hospital NHS Foundation Trust, for their help in managing the patient.
    Introduction The Riata and Riata ST family of 8-F and 7-F implantable cardioverter-defibrillator (ICD) leads are prone to failure involving exteriorization of the conductor cables. This resulted in a class I recall in December 2011 [1]. Lead failure is the result of a breakdown of the structural protease activated receptor integrity of the lead that may, or may not, present with abnormalities of electrical parameters. Here we report a unique mode of electrical failure that occurred in a patient with a Riata 1570 series dual coil lead. In this case, the first appropriate shock for ventricular fibrillation (VF) resulted in noise that in turn led to a series of inappropriate shocks mimicking an electrical storm leading to near-death.
    Case report Intracardiac electrograms were examined and Divergent transcription revealed that a total of 36 shocks had been delivered to the patient (Fig. 1). The first appropriate successful shock delivered 17.5J for VF (Fig. 1a). The ICD was programmed to 2 ventricular tachycardia (VT) zones (VT1<360ms, VT2<320ms) and a VF zone (<280ms). After the first successful shock, noise was detected, which was classified as VF resulting in an inappropriate shock (Figs. 1b and c). Repeated inappropriate shocks, delivered in response to noise, resulted in VT. This in turn resulted in further shocks, finally degenerating to VF (Fig. 1c). Further investigation of the ICD provided more clues. Electrical lead parameters were assessed and revealed a threshold of 0.5V at a pulse width of 0.4ms, sensed R waves of 9mV, high voltage lead impedance of 35Ω, and pacing impedance of 545Ω. Thus, there had not been any significant sudden changes in the electrical lead parameters prior to the presenting episode (Fig. 2). Repeated shocks had also increased the defibrillator charge time (to >28s) and depleted the battery voltage (to <2.45V), indicating an elective replacement interval (ERI) state. Fluoroscopic evaluation of the lead showed exteriorization of cables at the tricuspid annulus (Fig. 3).
    Discussion Duray et al. and Richards et al. reported a form of Riata lead failure that involved exteriorization of the lead cables (‘inside out’), which was a fluoroscopy finding noted in patients with abnormal lead parameters [1,2]. This was confirmed in subsequent single-center studies and various national registries, that ultimately led to a class I recall of Riata leads issued by St. Jude Medical in December 2011 [3–5].