Epicardial Lead Extraction after Sudden Cardiac Arrest

Objective: Coronary compression and cardiac strangulation are uncommon, yet potentially fatal complications that may occur after epicardial lead placement. We present the case of an asymptomatic male who required CPR and VA-ECMO during a routine pacemaker exchange. Methods: A 10 year old male with a history of long QT syndrome had epicardial leads and an ICD placed when he was 5 months old. The operative plan included assessment of ICD functionality and generator replacement. Results:  After connection to the new ICD generator, the patient had bradycardia with changes in end tidal CO2, and a weakly palpable carotid pulse. CPR was initiated and epinephrine bolused. ROSC was obtained after PEA for 30 seconds to 1 minute. The patient decompensated a second time, requiring CPR and cutdown of the femoral vessels for VA-ECMO cannulation. Echocardiography and a chest x ray revealed no signs of tamponade, hemothorax, or pneumothorax. Cardiac catheterization revealed the ICD lead wrapped twice, circumferentially around the body of the ventricles and compressed the left anterior descending coronary artery. Redo sternotomy was performed, and all leads were extracted. Coronary angiogram demonstrated relief of the extracardiac compression. The patient was weaned off ECMO after 4 days and was extubated POD 6. He was stable on nadolol 40mg and discharged POD 14. Conclusions: The literature on this phenomenon is limited to case reports and single-institution studies. This case underscores the importance of monitoring patients with epicardial leads and provides an example of how emergent action can prevent unnecessary mortality in this population.

N/A

N/A

N/A

N/A

None

N/A

Mah DY, Prakash A, Porras D, Fynn-Thompson F, DeWitt ES, Banka P. Coronary artery compression from epicardial leads: More common than we think. Heart Rhythm. 2018;15(10):1439-1447. doi:10.1016/j.hrthm.2018.06.038  Macicek, S. L. , Cannon, B. C. , Kyle, W. B. , Krishnamurthy, R. , Breinholt, J. P. & Ing, F. F.  (2011).  Dynamic Coronary Artery Compression by Pacemaker Lead.  Circulation,  124 (16),  1792-1794.  doi: 10.1161/CIRCULATIONAHA.110.980243. Dzhaffarova OY, Svintsova LI, Kartofeleva EO, et al. Cardiac Strangulation in Children: Asymptomatic Complication of Epicardial Pacing. JACC Case Rep. 2022;4(14):857-861. Published 2022 Jun 22. doi:10.1016/j.jaccas.2022.05.014  Miyagi C, Ochiai Y, Ando Y, et al. A case of cardiac strangulation following epicardial pacemaker implantation. Gen Thorac Cardiovasc Surg. 2020;68(12):1499-1502. doi:10.1007/s11748-020-01337-y  Tonko JB, Rinaldi CA. Non-traditional implantable cardioverter-defibrillator configurations and insertion techniques: a review of contemporary options. Europace. 2022;24(2):181-192. doi:10.1093/europace/euab178  Fortescue EB, Berul CI, Cecchin F, Walsh EP, Triedman JK, Alexander ME. Patient, procedural, and hardware factors associated with pacemaker lead failures in pediatrics and congenital heart disease. Heart Rhythm. 2004;1(2):150-159. doi:10.1016/j.hrthm.2004.02.020  Carreras EM, Duncan WJ, Djurdjev O, Campbell AI. Cardiac strangulation following epicardial pacemaker implantation: a rare pediatric complication. J Thorac Cardiovasc Surg. 2015;149(2):522-527. doi:10.1016/j.jtcvs.2014.10.094