EXPERIENCE OF TREATMENT OF CARDIAC PERFORATIONS BY ENDOCARDIAL ELECTRODES FOR PERMANENT PACING

To assess the experience of treatment of patients with myocardial perforations and to develop an algorithm of their management, the outcomes of 2,145 implantations of different devices were analyzed. 1,248 electrodes were implanted into the atria; 2,095 ones, into the ventricles, including 209 electrodes for cardioverters-defibrillators (ICD). Only endocardial steroid-eluting electrodes with active fixation were used. The atrial electrode was usually positioned in the right auricle, and in case of high pacing thresholds, in the free wall. The ventricular electrode was positioned in the medial or upper parts of the inter-ventricular septum of the right ventricle; no apical position was used. As the final step of the procedure, chest X ray was performed, with the corresponding image downloaded into the electronic medical chart. On the next day after the procedure, chest X-ray in two projections was recorded, ECG was recorded once again, and the pacemaker testing was performed. The cardiac perforation was defined as development of hemopericardium and/or extracardiac location of the electrode revealed on X-ray images. In the case of presence of hemodynamic alterations, pericardial drainage was made using the Marfan’s technique under the radiological control. The drainage was removed after 1 2 days of absence of pericardial effusion. Eight perforations of myocardium were documented. The perforations were located in the right atrium (RA) in 3 cases and in the right ventricle (RV) in 5 cases. Five of 8 perforations were accompanied by hemopericardium. In 4 of them, the pericardial cavity drainage was performed; in one case the medical treatment was sufficient. Hemopericardium was detected in all cases of the RA perforation. The RV perforation was accompanied by hemopericaridum only in 2 cases of 5. Six of 8 perforations were of an acute nature; in one case, the sub-acute perforation of RV was detected (3 days following the procedure); and in one more case, the late RV perforation took place (6 months following the procedure). Three perforations of the RV were asymptomatic; they were revealed during scheduled X-ray assessments and were accompanied by dysfunction of the right ventricular electrode (both altered sensing and pacing). The electrode reposition was required in 3 cases when the electrode was located extracardially and its activity was impaired; in 2 cases of the RV perforation in them, no hemopericardium was detected. No cases of the myocardial perforation led to a subject’s death, no open-heart surgical intervention was required. In four cases, critical hemodynamic disturbances occurred; they required emergency pericardial drainage with evacuation of 250 350 ml of blood. After that, no blood accumulation in the pericardial cavity was observed. In the current series of examinations, the electrode reposition was required only in one of five cases of hemopericardium. In all cases, the follow-up X-ray examination was sufficient to reveal the extra-cardiac electrode location; no computer tomography of the chest was required. The authors’ strategy of management of cardiac perforations based on the clinical signs and symptoms: hemopericardium with hemodynamic alterations was a subject of drainage and subsequent echocardiographic follow-up (in 1 hour, then every 3 hours) if the X-ray examination did not show an evident extracardial location of the electrode tip. In case of hemopericardium with stable hemodynamics and absence of signs of an increased pericardial effusion, and electrode dysfunction, the conservative therapy took place. In case of acute or sub-acute perforations without hemopericaridum but with the electrode dysfunction, the transcutaneous electrode reposition was carried out taking into the account the possibility of immediate start of open-heart surgery if the cardiac tamponade occurs. Thus, the presented experience of management of the cardiac perforations by endocardial electrodes permitted the authors to develop the algorithm based on assessment of hemodynamic alterations in case of hemopericardium as well as on presence/lack of extracardiac location of dislocated electrodes.

cardiac pacemaker, cardioverter-defibrillator, endocardial electrode, active fixation, cardiac perforation, hemopericardium, electrode dislocation, pericardial cavity drainage

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