1. CIED implant trouble shoot in cath.
room
Allied Professional Training, THRS
19st, Oct, 2013
黃鴻儒 醫師

2. Classification of Pacemaker Complications by Clinical
Presentation
Implant related
complication
Post-implant
complication
New symptoms
secondary to
PPM
Asymptomatic
ECG
abnormalities
Pneumothorax (
due to subclavian
puncture
Other complications
of subclavian
puncture
Hematoma
Lead perforation
Lead dislodgment
Lead placement in
the systemic
circulation
Lead fracture
Lead insulation
defect
Loose lead
connector
Extracardiac
stimulation
Pacemaker
syndrome
Pacemaker
mediated
tachycardia
Infection
Pain
Failure to capture
Failure to sense
Oversensing
(failure to output)
Change in paced
rate
Twiddler syndrome

3. Implantation Techniques - Acute








Pneumothorax
Hemothorax
Pneumo- hemothorax
Brachial plexus injury
Arterial puncture
Chylothorax
Infection
Pocket Hematoma / Seroma

4. Acute Venous Stenosis
Limiting Access

5. Pneumothorax
 In PASE Trial: 1.97%

7. Acute Hemothorax Complicating Subclavian
Venipuncture
Within 15 minutes of
subclavian arterial
puncture
3 hours postprocedure

8. Management for Pneumothorax
 Suspect lung puncture  withdraw the needle, wait a
moment to make certain that a rapid-onset, large, markedly
symptomatic pneumothorax is not occurring.
 If a pneumothorax does develop, it may not even be
apparent radiographically at the end of the procedure.
 If a lung puncture has occurred, obtaining another upright
chest radiograph 6 hours after completion of the
procedure is advisable.
 If a pneumothorax has developed, a chest tube or
catheter evacuation procedure may be necessary,
although frequently, a small to moderate pneumothorax
that is not expanding can be managed conservatively
without evacuation.

9. Air Embolism during Permanent Pacemaker
Procedures
 Avoid air embolism (esp. for largebored sheaths)
 press proximal end of sheath and
instruct patient to hold breath during
pacing lead insertion
 use of introducer sheath with
hemostatic valve

10. Prevention of Air Embolism during PPM Procedures

11. Myocardial Perforation
 When recognized, lead MUST
be pulled back ?!
 Be prepared for tamponade
 May require open procedure
to manage but heart usually
seals itself.

12. Diaphragmatic Stimulation
Lead in Cardiac Vein
Lead inadvertently placed into post.
Cardiac V

14. Implantation Procedure #1
Recorded
immediately postimplant.
The atrial sensing
threshold was 1.8
mV, the ventricular
sensing threshold
was 12 mV
As Vp
Vs
As Vp
Marker of
pacemaker
What is the cause of this behavior?

15. Implantation Procedure #1
P wave marker
is above a QRS
As Vp
R wave marker
is above a Pwave
Vs
As Vp
Leads are switched in the header

16. Implantation Procedure #2
The tracing shown below was recorded with the pacemaker in
the DDD mode, 4 V output on both atrial and ventricular
channels, base rate 60 ppm and AV delay 165 ms. What is the
problem if any?
Surface ECG
Marker
A IEGM
A : A pacing
V : V pacing

17. Implantation Procedure #2
Loss of V-capture, Patient is in a 2:1 heart block, need to recheck
the V lead position.
Loss of V
capture
A : A pacing
V : V pacing
Loss of V
capture
Loss of V
capture
Loss of V
capture

18. Implantation Procedure #3
The device is hooked up and the following ECG is
seen. Is this normal? If not, what is occurring?
A : A pacing
P : A Sensing
V : V Pacing
R : V Sensing

19. Implantation Procedure #3
Good A capture
A pacing with
V sense to
follow
A pacing with
V sense to
follow

20. Implantation Procedure #3
PVC falls upon the AP which V
pacing follows inducing the loss
of AV synchrony
PVC
PMT

21. Pacemaker-Mediated Tachycardia
 Initiated by a loss of AV synchrony





PVC most common cause
Atrial loss of capture
Atrial undersensing
PAC
Magnet removal
Retrograde P
Ventricular Channel Must Respond
PMT at Max Track Rate (or Slower)

22. How to terminate PMT




Place magnet
Change to VVI (Use programmer)
Program longer PVARP (Use programmer)
Use PMT termination algorithm (pacemaker function)
Retrograde P
PMT
terminated
Auto-Detect Algorithm

23. Implantation Procedure #4
This ECG strip is handed to you post implant. What is
the most likely diagnosis?

24. Implantation Procedure #4
1. A pacing and accompany with captured QRS, it indicated A lead
dislodge to ventricle.
2. No V captured waveform followed by V pacing spike due to ventricular
is in the physical refractory.
3. On occasion, AV delay is short because of safety pacing.
Short AV delay
(120 ms) : Safety
pacing
Normal AV
delay
Ap Vp Ap Vp Ap Vp Ap Vp Ap Vp

25. Implantation Procedure #4
atrial lead
in the ventricle

27. Pulse Generator Pocket- Chronic

Pain - pocket neuralgia




Erosion




Incorrect tissue plan
Incorrect location - too lateral
Smoldering infection
Pressure necrosis
Smoldering infection
Migration
Twiddler’s Syndrome

28. Bipolar
 In-line Bipolar conductor construction
 Two Coils
 Will have several strands
 Trifiler, Quadrafiler, 5 filer, etc.
Inner insulation
 Two layers of Insulation
Outer insulation
Outer coil
(Anode)
Inner coil
(Cathode )

29. Conductor Coil Fracture

30. Implantation Techniques - Late

Rib-Clavicle crush
Insulation damage
Conductor fracture

Tight anchoring sleeve
Insulation damage
Conductor fracture

Loose anchoring sleeve
Lead dislodgment
Twiddler’s Syndrome

31. Rib-Clavicle Crush
Insulation Damage
Insulation is
radiolucent,
deformity in
conductor coil
identifies
location of
problem

32. Rib-Clavicle Crush- Conductor Fracture
Dotted line identifies lower edge of
clavicle

33. Loose Anchoring Sleeve
Twiddler’s Syndrome

34. Loose Anchoring Sleeve
 Lead allowed to “pull
back”
 Traction at electrodetissue interface causes
high thresholds
 Predispose to
dislodgment
Note loss of heel on leads

35. Loose Anchoring Sleeve
Dislodgment
Dual Lead
July 2001
Day 1 postimplant
Day 3 postimplant

36. Tight Anchoring Sleeve
Damage to Lead

37. Tight Anchoring Sleeve
 Leads from 4 different
mfg’s
 Tight anchoring sleeve
pushes insulation
between conductor
coils “pseudofracture”
 Areas of major stress

38. Pacemaker Lead Placement
 Myocardial perforation (Pacemaker lead perforation rate:
0.1~0.8%, ICD lead perforation rate : 0.6~5.2%)
 Placement in left ventricle via
 Patent foramen ovale
 Septal perforation
 Arterial entry
 Dislodgment: The most common complication( PAcemaker
Selection in Elderly : 2.2%)
 Atrial dislodgment : 3%
 Ventrical dislodgement : below 2%
 Diaphragmatic stimulation
 Directly - lead in cardiac vein
 Directly - myocardial perforation
 Indirectly - phrenic nerve stimulation

39. Thrombotic Problems

Venous thrombosis
Superior vena cava syndrome


Pulmonary embolism
Systemic embolism
Endocardial lead on left side of
circulation
Paradoxical embolism

40. Venous Thrombosis
Chronic thrombosis with
collaterals
SVC Syndrome

41. Chronic Venous Thrombosis
 Superficial dilated veins
in upper extremity and
chest
 Localized to side of
chest where
pacemaker is located
 No specific treatment
July
2001

42. Superior Vena Cava Syndrome
 Symptoms
 Swelling of arms
 Fullness in head &
neck
 Increased JVP
 Management
 Anticoagulation
 Surgical reconstruction
 Lead explantation
 Venoplasty &
Stent placement
“Beaver Syndrome”

43. Management of Pocket Hematoma
 Observation and close
follow-up
 Soft
 Minimal to no
tenderness
 Surgical evacuation
 Tense pocket
threatening suture line
 Weeping suture line
 Severe pain
 Immunocompromised
host
August
2001

44. Pulse Generator Pocket - Chronic

Pain - pocket neuralgia
Incorrect tissue plane
Incorrect location - too lateral
Smoldering infection

Erosion
Pressure necrosis
Smoldering infection
Incorrect location
too lateral
too superficial


Migration
Twiddler’s Syndrome

45. PAIN
Incorrect Tissue Plane
Furman S, PACE 2001; 24: 1224-1227

46. Proper Location of Pulse Generator
Note the use of the
Cephalic Vein! Pocket
is then placed medial to
the incision on the
anterior chest wall.
Furman S, PACE 2001; 24: 1224-1227

47. Improper Location of Pulse Generator
If the pacemaker is
placed too lateral, it
will cause discomfort
every time the patient
rotates arm forward
Furman S, PACE 2001; 24: 1224-1227

48. Pressure Necrosis
Thinning and
discoloration at lateral
margin
Total breakdown and 2°
Infection

49. Smoldering Pocket Infection with draining fistula
 Presented 2 years post
implant
 Eschar and draining
fistula at edge of incision,
surrounding erythema
 Waxed and waned on
oral antibiotics
 Local cultures were
negative
January 24, 2002

50. Chronic Smoldering Infection
Pulse Generator Explanted but Not Lead
 Low grade pocket infection
 Managed by explanting
pulse generator but leaving
lead in place
 2 weeks of antibiotics
 Initial good result
 MUST remove all foreign
material from pocket
9 months post-PG explant

51. Pacemaker Extrusion
Clinical history: 61 year old
man implanted 9 months
previously for complete heart
block. Did not consider
follow-up to be necessary. Not
concerned when device began
to show through the skin.
Only when it fell out did he
call his physician. Cultures
grew Staph epidermidis.
Unknown if a primary infection
caused the erosion or the site
was secondarily infected once
it was open to the skin.
Parsonnet V, Circulation 2000; 102:

52. Electromagnetic Interference
 Electromagnetic Interference (EMI) involves electrical
and/or magnetic signals in the environment or arising
from the body that impact the normal function of the
implanted pacing system.

53. Community Based EMI Influences






Microwave ovens
Cellular telephones
Electronic article surveillance
Power stations
Arc welding equipment
CB and Ham Radio equipment

54. Hospital Based EMI Influences

Cardioversion and Defibrillation
External
Internal


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
Electrocautery
Transcutaneous Electrical Nerve
Stimulators (TENS)
Magnetic Resonance Imaging (MRI)
Radiation Therapy (XRT)
Electroconvulsive Therapy (ECT)

55. Potential Effects of EMI

Temporary
Noise mode reversion
Inhibition - sensing
Programming change

Permanent
Damage to pulse generator
Tissue damage at electrode -myocardial
interface
Increase in capture threshold
Increase in sensing threshold
Lead damage
Patient injury

56. THANKS

57. THANKS