Late Pulmonary Embolization of a Retained Pacemaker Electrode Fragment after Attempted Transatrial Extraction

Abstract

Embolization of pacemaker electrode fragments into the pulmonary circulation is a rare complication following transvenous pacemaker implantation. One such case is reported here. In a 67-year-old patient, a battery pocket infection developed after transvenous pacemaker implantation and subsequent surgical revision. After removal of the pacemaker and ventricular pacing lead, the atrial lead broke within the superior vena cava when prolonged traction was applied after frustrating attempts to extract the electrode. Attempts to extract the fragment transvenously using endoscopic forceps were unsuccessful. Due to firm fixation of the electrode by extensive fibrous scar tissue in the atrial wall, a further attempt to remove the retained electrode fragment by atriotomy also failed. On the first postoperative day, the fragment migrated to the left pulmonary artery, from where it was successfully extracted by means of a Dormier basket.

Application of Novel Technologies in Cardiac Electrotherapy to Prevent Complications

“…The symptoms of such a dislocated lead are not specific and include, for example, fever, cyanosis, and decreased exercise capacity, or may not be present at all [15,16,24]. Sometimes, dislodgement, which occurs through the creation of turbulent blood flow, leads to increased thrombotic status and can result in thrombi around the lead, which may occasionally cause a pulmonary embolism [26,27]. As a routine CXR usually allows doctors to confirm dislocation with a very high probability [14,15,17,24,25,28,29], multimodal imaging is remarkably beneficial in the diagnostic pathway [30].…”

A rare complication of transvenous lead extraction - pulmonary embolization with a broken distal lead fragment

“…In the literature we can find reports of only a few similar events with a different broken lead fragment length [4][5][6][7][8][9][10]. The first case was described in 1977 [4].…”

“…In five reported cases the lead fragment was left in the pulmonary vascular bed and the patients remained under observation due to lack of clinical signs [4][5][6][7]. Three patients only underwent the procedure of remaining lead fragment extraction using transvenous tools such as an Amplatz goose neck snare kit for intravascular foreign body retrieval, basket or lasso catheters [8][9][10]. All procedures were successful, without any complications.…”

Retrieval of Pacemaker Lead Tip Embolized into the Distal Pulmonary Arterial Bed during Extraction Procedure

“…Embolism into the hypogastric vein 11 and into the superolateral vein in the spinal canal causing root compression have been anecdotically described, 12 such as the paradoxical embolism of a lead fragment in a leg artery 13 . However, pulmonary embolization of lead fragments is the most frequently observed event and it has been described from the first extraction attempts, at the end of the 1970s 14–17 . In some of these cases, the lead fragments were left in place intravasally with the only development being late pleuritis 16 ; in other cases, surgical removal was performed 15 or embolization resulted in a fatal outcome 14 .…”

“…However, pulmonary embolization of lead fragments is the most frequently observed event and it has been described from the first extraction attempts, at the end of the 1970s 14–17 . In some of these cases, the lead fragments were left in place intravasally with the only development being late pleuritis 16 ; in other cases, surgical removal was performed 15 or embolization resulted in a fatal outcome 14 . Recently, Eckart and co‐workers 18 reported the case of a 46‐year‐old woman with endovascular leads placed 15 years previously requiring extraction.…”