Authors: Kyu-Yong Ko, Sung Eun Kim, Ji-Won Hwang, June Namgung, Sung Woo Cho
Categories: Rhythm Disorders and Electrophysiology, cardiac perforation, chiropractic therapy, pacemaker dislodgement, shoulder surgery
Source: JACC Case Reports
Authors: Kyu-Yong Ko, Sung Eun Kim, Ji-Won Hwang, June Namgung, Sung Woo Cho
Cardiac perforation caused by pacemaker lead dislodgement is a rare but potentially fatal complication. Although early dislodgement is a common cause in such cases, external mechanical forces can also cause delayed perforation.
An 83-year-old man with a pacemaker presented with dyspnea and syncope. Chest radiography showed right ventricular lead migration with perforation, and echocardiography confirmed hemopericardium. Lead dislodgement was suspected to be caused by prior chiropractic therapy for shoulder rehabilitation. The dislodged lead was extracted, and a new lead was repositioned in the interventricular septum for left bundle branch pacing.
This case highlights the risk of delayed cardiac perforation attributable to mechanical stress caused by rehabilitation and underscores the need for patient education and cautious placement strategies to minimize complications.
Patients with pacemakers should be counseled regarding the risks of physical activity. Multimodal imaging aids in early detection of lead-related complications.
An 83-year-old man presented to our emergency department with dyspnea and syncope. On arrival, his vital signs were as blood pressure, 119/59 mm Hg; heart rate 39 beats/min; respiratory rate 18 breaths/min; temperature 36.6 °C; and oxygen saturation 95% on ambient air. The patient reported that the symptoms appeared suddenly several days before presentation. He also reported feeling comfortable at rest but that the symptoms worsened with physical activity. Cardiac auscultation revealed a slow but regular rhythm without murmur.Visual SummaryDelayed PM-Related Complication During Shoulder Rehabilitation
The patient had a history of dual-chamber pacemaker (PM) implantation (ACCOLADE MRI EL; Boston Scientific) for complete atrioventricular block at the age of 77 years. The right ventricular (RV) lead was an active fixation INGEVITY MRI pacing lead (Boston Scientific). In addition, the patient had a history of left shoulder pain that was diagnosed as rotator cuff arthropathy. One year before presentation, he had undergone shoulder surgery on the ipsilateral side of the PM because the pain had not improved despite medical treatment. One month after discharge without postoperative complications, he visited the cardiology outpatient clinic. A PM assessment was performed and indicated that the device was functioning properly; no significant differences from those observed during the previous evaluation were noted. The pacing thresholds were 1.0 V at 0.4 ms for the A lead and 1.2 V at 0.4 ms for the V lead. The sensing thresholds were 0.75 mV for the P-wave and 2.5 mV for the R-wave. The lead impedances were 734 Ω for the A lead and 681 Ω for the V lead. Atrial pacing was recorded at 3% and ventricular pacing at 98%. Chest radiography showed no changes in the position of the PM leads when the preoperative images (Figures 1A and 1B) were compared with the postoperative images (Figures 1C and 1D).Figure 1Sequential Chest Radiography Images Before and After Shoulder SurgeryThe position of pacemaker leads remained unchanged between the preoperative (A, B) and postoperative (C, D) periods.
The differential diagnoses included acute coronary syndrome, acute decompensated heart failure, or PM malfunction.
An electrocardiogram showed complete atrioventricular block with pacing spikes but no subsequent QRS complexes, indicating capture failure. However, prior PM interrogation had confirmed proper functionality (Figure 2). Chest radiography revealed that the ventricular lead had migrated laterally and superiorly and that the PM lead tip extended beyond the cardiac border, suggesting cardiac perforation (Figures 3A and 3B). Laboratory tests revealed the following blood urea nitrogen, 36.2 mg/dL; creatinine, 1.62 mg/dL; sodium, 139 mEq/L; and potassium, 5.0 mEq/L, with no evidence of electrolyte imbalance. The creatinine kinase-myoglobin binding level was 2.8 ng/mL (within the normal range). However, an elevated troponin I level (268.4 pg/mL; normal <34.2 pg/mL) was observed. Transthoracic echocardiography (TTE) was immediately performed to confirm cardiac perforation caused by the PM lead. However, conventional echocardiographic views did not reveal any signs of cardiac perforation (Figures 4A and 4B). We attempted to trace the ventricular lead to the RV apex using an off-axis view and confirmed that the lead penetrated the apical lateral wall of the RV. A hypoechogenic layer was detected near the cardiac perforation area, indicating a small amount of hemopericardium (Figures 4C and 4D, Video 1). On 3-dimensional echocardiography, the lead penetrating the RV wall and the surrounding hemopericardium was more clearly observed (Figure 5, Video 2). This pericardial effusion was not detected on the TTE performed during the PM implantation 5 years earlier. A comprehensive review of the patient's history revealed that he regularly received chiropractic therapy to rehabilitate his surgically treated shoulders. He stated that the chiropractic therapist was unaware of his prior PM implantation and explained that the therapy involved repeatedly abducting his operated shoulder to 180°. A PM assessment revealed failure to capture.Figure 2Evaluation of the 12-Lead ElectrocardiogramsAn electrocardiogram performed during a prior pacemaker evaluation confirmed proper function (A). However, a subsequent electrocardiogram performed in the emergency department showed bradycardia and complete atrioventricular block (B). Although pacemaker spikes were evident, the absence of the corresponding QRS complex indicated pacing failure.Figure 3Chest Radiography in the Emergency DepartmentChest radiography shows that the RV lead migrated laterally and superiorly compared with its position observed during a previous examination after shoulder surgery (A, B). The RV lead extended beyond the cardiac contour, suggesting cardiac perforation (arrows). RV = right ventricle.Figure 42-Dimensional Echocardiography of Conventional and Off-Axis ViewsNo significant pericardial effusion is observed in the apical and subcostal views (A, B). However, biplane imaging of the off-axis views identified cardiac perforation caused by the pacemaker lead (arrows) (C, D).Figure 53-Dimensional EchocardiographyThree-dimensional transthoracic echocardiography provides a clearer visualization of cardiac perforation by the pacemaker lead (arrow) and a small amount of pericardial effusion.
Because of suspected lead malfunction and related cardiac perforation caused by the lead, PM lead extraction and revision were performed under fluoroscopic and echocardiographic guidance with surgical backup to mitigate potential complications, including myocardial injury, hemopericardium progression leading to cardiac tamponade, tricuspid valve injury, and lead adhesion to the superior vena cava, which could complicate extraction. The lead was successfully removed without complications, and a new lead was repositioned in the interventricular septum for left bundle branch pacing (LBBP) (Figure 6).Figure 6Chest Radiography and Electrocardiogram Results After Revision of the RV LeadChest radiography and electrocardiogram images after removal of the dislodged RV lead and implantation of a new RV lead using the left bundle branch pacing technique. Radiographs demonstrate the newly positioned RV lead directed toward the interventricular septum (A, B). The electrocardiogram shows a narrow QRS duration of 138 ms, indicating successful conduction system pacing (C). RV = right ventricular.
Evaluations confirmed stable lead placement and proper device function. Dyspnea resolved, and the patient was discharged in stable condition with instructions to undergo follow-up in the outpatient clinic. Further discomfort has not been reported.
Complications such as cardiac perforation and pacing malfunction caused by a dislodged lead can be fatal for patients who are PM dependent. Cardiac perforation caused by dislodged PM leads occurs in <1% of cases but can be life-threatening.^1^^,^^2^ Clinical manifestations of cardiac perforations vary, ranging from cardiac tamponade due to hemopericardium and chest pain caused by diaphragmatic stimulation to syncope resulting from pacing failure. Our patient experienced dyspnea and syncope.
The patient had a screw-type RV lead implanted at the RV apex. Previous studies have reported that active screw-type leads are associated with a higher complication rate than passive-type leads and that perforation occurs more frequently at the RV apex than at nonapical sites.^3^^,^^4^ This increased risk is attributed to the greater mobility of pacing leads at the RV apex and the gradual thinning of the RV wall from base to apex.^5^ Traditionally, the RV apex has been the preferred site for lead placement because of its accessibility and ease of positioning. However, RV apical pacing can result in electrical dyssynchrony, potentially leading to left ventricular dysfunction and a higher risk of perforation, as observed with this case.^6^ To reduce these risks, LBBP has emerged as a more physiological alternative that provides synchronized ventricular activation and maintains a low, stable capture threshold. Consequently, in our patient, the new RV lead was implanted using the LBBP technique to enhance pacing efficacy and safety.^7^
The lead is the most frequently failing component of the PM system because of the continuous mechanical stress it undergoes with each cardiac cycle and movement of the shoulder girdle.^6^ Therefore, the guidelines recommend that the shoulder on the ipsilateral side where the PM is implanted should not be moved for 4 to 6 weeks after implantation.^8^ Over time, fibrous tissue forms around the lead, thus securing it within the heart; however, mechanical stress may alter its position.
Periprocedural and postprocedural care of the shoulder on the side ipsilateral to the implanted device is essential. When consulting with the orthopedist, we emphasized the need for caution during shoulder surgery. The patient did not report any PM-related discomfort after surgery; however, complications arose during chiropractic therapy during the rehabilitation period. Chiropractic therapy is performed to treat upper extremity conditions such as frozen shoulder, tennis elbow, and carpal tunnel syndrome.^9^ Repetitive shoulder abduction to 180°, as experienced by this patient during chiropractic therapy, can impose mechanical stress on the PM lead, potentially resulting in lead dislodgement. Therefore, it is necessary to inform chiropractic therapists about the presence of implanted PMs and emphasize the need for careful shoulder joint manipulation. In addition, conducting more frequent follow-ups with electrocardiography and chest radiography may be necessary to monitor pacing issues during the rehabilitation period.
There is no consensus regarding the optimal imaging strategy for identifying cardiac perforations. The diagnosis can be aided by a combination of chest radiography, fluoroscopy, TTE, and computed tomography.^10^ Although computed tomography provides better visualization of the perforation site, its related radiation exposure is a disadvantage. In contrast, TTE is a noninvasive diagnostic tool that enables real-time assessment of cardiac motion and surrounding structures without radiation. In addition, TTE allows the evaluation of hemodynamic features such as cardiac tamponade. In cases such as ours, the PM lead position may not be clearly visible in conventional views. The guidelines suggest using off-axis views in such situations; in addition, using the latest technologies, such as biplane or 3-dimensional imaging, can aid in the diagnosis. We confirmed cardiac perforation caused by a PM lead in our patient solely using chest radiography and TTE.
This case highlights the importance of monitoring patients with PM during ipsilateral shoulder surgery and postoperative rehabilitation. Moreover, it is advisable to use a team approach that includes cardiologists, orthopedists, and chiropractic therapists to treat patients with PM who require shoulder surgery. This team-based approach ensures that all relevant patient information is shared among health care providers, thus facilitating comprehensive and coordinated care.
To our knowledge, this is the first case of delayed RV perforation caused by a dislodged PM lead attributable to chiropractic rehabilitation therapy after ipsilateral shoulder surgery. Although PM implantation is a safe procedure, mechanical stress on the lead, particularly that from repetitive or forceful movements of the ipsilateral shoulder, can result in serious complications. This report underscores the importance of patient education regarding the risks of physical manipulations after device implantation. In addition, it emphasizes the need for collaborative care among cardiologists, orthopedic surgeons, and physical therapists to optimize patient outcomes. Early recognition and prompt intervention guided by multimodal imaging are critical to the effective management of such complications.
This study was approved by the Institutional Review Board of Inje University Ilsan Paik Hospital (No. 2024-02-009). The requirement for informed consent was waived.
The data underlying this article are available in the article and online Supplementary Material.Take-Home Messages•Clinicians should advise patients with implanted pacemakers regarding the potential risks of chiropractic therapy and other similar physical manipulations.•Early and accurate diagnosis is crucial for managing complications of pacemaker lead dislodgement and cardiac perforation, with echocardiography serving as a valuable noninvasive diagnostic tool.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose