Case Report
Transmyocardial Migration of a Temporary Epicardial Pacing Wire: A Pediatric Case Report
World Journal for Pediatric and Congenital Heart Surgery 2014, Vol. 5(2) 315-317 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135113515278 pch.sagepub.com
Marjorie A. Gayanilo, MD1, Eliot R. Rosenkranz MD1, Satinder K. Sandhu, MD1, and Richard E. Kardon, DO1
Abstract Transmyocardial migration of a retained temporary epicardial pacing wire has been rarely reported in adult patients after heart surgery. We present the case of a child in whom a temporary epicardial pacing wire was discovered incidentally in the right ventricular outflow tract one year after surgical repair of congenital heart disease. The pacing wire was subsequently extracted using the snare method during cardiac catheterization. Clinicians caring for patients after congenital heart surgery should be aware of this uncommon though potentially life-threatening complication. Keywords epicardial pacing wire, congenital heart disease, congenital heart surgery, postoperative care Submitted July 23, 2013; Accepted November 6, 2013.
Introduction The routine placement of temporary epicardial pacing wires is essential for the diagnosis and treatment of arrhythmias as well as optimizing hemodynamics after repair of congenital heart disease. The pacing wires are usually removed prior to discharge; however, if there is undue resistance, the wires are cut at the skin and allowed to retract into the pericardial sac. Complications arising from a retained epicardial wire have been reported in adults. We describe a pediatric case of a retained temporary epicardial pacing wire that migrated into the right ventricular outflow tract following congenital heart surgery.
Case Report Our patient is a 14-month-old child who was born with an aortic origin of the right pulmonary artery. The diagnosis was made by echocardiography after she was hospitalized at four weeks of age with progressive respiratory distress. At five weeks of age, she underwent surgical repair consisting of reimplantation of the right pulmonary artery into the main pulmonary artery. Intraoperatively pacing wires were simply placed on the epicardium of both the right atrial lateral wall and the right ventricular free wall and then subsequently secured to the surface with a 6-0 polypropylene suture. She had an uneventful postoperative course. Prior to hospital discharge, the pacing wires were cut at the level of the skin after an unsuccessful attempt to remove them with gentle traction.
The child subsequently developed right pulmonary artery stenosis and underwent transcatheter balloon dilation at four months of age. At routine follow-up evaluations, serial echocardiograms demonstrated Doppler evidence of significant residual right pulmonary artery stenosis. It seemed likely that reintervention would be necessary, and the hope was to postpone the procedure until it was feasible to place an endovascular stent at approximately one to two years of age. During a follow-up echocardiogram performed at 14 months of age, a puzzling linear density was discovered within the right ventricle that extended into the right ventricular outflow tract (Figure 1; Supplemental video). To help elucidate the identity of this finding, a chest radiograph was obtained and revealed superior migration of one of the retained pacing wires (Figure 2). After reviewing these studies, a plan was made for transcatheter removal of the migrated epicardial wire. The child was admitted to the hospital and underwent computed tomography with contrast to assess for associated infection. The scan showed no evidence of an abscess, and it confirmed our suspicion that a retained epicardial pacing wire
1
Department of Pediatric Cardiology, Holtz Children’s Hospital, University of Miami Miller School of Medicine, Miami, FL, USA Corresponding Author: Marjorie A. Gayanilo, Department of Pediatric Cardiology, Holtz Children’s Hospital, University of Miami Miller School of Medicine, Miami, FL 33136, USA. Email: [email protected]
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World Journal for Pediatric and Congenital Heart Surgery 5(2)
Figure 1. Two-dimensional transthoracic echocardiogram (subcostal sagittal view) demonstrating a linear echodensity in the right ventricle and extending into the right ventricular outflow tract.
had eroded through the right ventricular wall and migrated superiorly into the right ventricular outflow tract (Figure 3). In the cardiac catheterization laboratory, a 5F Cook sheath was advanced to the main pulmonary artery with fluoroscopic guidance, and a 25-mm snare was used to retrieve a 4.6-cm segment of an epicardial pacing wire (Figure 4). Following the procedure, the child was observed overnight in the pediatric intensive care unit. Since the cardiac catheterization, she has had an uneventful course.
Discussion Over the past four decades, temporary epicardial pacing wires have been routinely placed in patients during cardiac surgery. Although these wires are usually removed, when resistance is encountered they are cut at the skin level and allowed to retract. Complications related to retained epicardial pacing wires have been well described by Del Nido and Goldman.1 One of these complications, transmyocardial migration of retained epicardial pacing wires, appears in the literature as only a small number of case reports. These reports all involve older adults and in the majority of cases have been discovered incidentally following coronary artery bypass procedures.2–8 In two instances, symptoms were directly attributed to the intracardiac migration of an epicardial pacing wire. In one patient, postoperative bleeding resulting in hypotension led to the diagnosis ten hours after heart surgery.6 Another patient developed ventricular tachycardia and cardiac arrest three years after a coronary artery bypass procedure.7 The incidental discovery by Worth et al8 of a retained pacing wire 24 years after its placement
Figure 2. Anteroposterior (A) and lateral (B) views of a chest x-ray showing an epicardial pacing wire that has migrated superiorly and is seen within the cardiac silhouette.
highlights the potential for very remote discovery of this complication. In this report, we present the case of a retained epicardial pacing wire that migrated into the right ventricular outflow tract one year after repair of congenital heart disease. Notably, the temporary wires had been secured to the epicardial surface of the atrium and the ventricle during the original surgical procedure but had not been inserted into, or passed through,
Downloaded from pch.sagepub.com at PENNSYLVANIA STATE UNIV on March 14, 2015
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Figure 4. Photograph of the retrieved epicardial pacing wire.
echodensity in the right ventricle and extending into the right ventricular outflow tract.
References Figure 3. Cardiac computed tomography demonstrates a linear opacity (arrow) within the right ventricle and extending into the right ventricular outflow tract.
the epicardium at the time of insertion. Although relatively uncommon, this particular complication has the potential for significant morbidity and therefore should prompt the development of novel lead technology and fixation techniques aimed at prevention. Those involved in caring for patients after congenital heart surgery should be aware of potential wire migration, allowing for prompt diagnosis and removal. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material The online video is available at http://wjpchs.sagepub.com/supplemental. Video 1. A ten-second clip of a two-dimensional transthoracic echocardiogram (subcostal sagittal view) demonstrating a linear
1. Del Nido P, Goldman BS. Temporary epicardial pacing after open heart surgery: complications and prevention. J Cardiac Surg. 1989; 4(1): 99-103. 2. Horng GS, Ashley E, Balsam L, Reitz B, Zamanian RT. Progressive dyspnea after CABG: complication of retained epicardial pacing wires. Ann Thorac Surg. 2008;86(4): 1352-1324. 3. Spellberg RD, Dobkin JE, Soleymani S. Intraoperative migration of operatively placed epicardial pacing leads. Ann Thorac Surg. 2012;93(5): 1713-1715. 4. Hong SN, Rosenzweig B, Crooke GA, Kronzon I, Srichai MB. Inside and out an epicardial lead gone array. Tex Heart Inst J. 2011;38(2): 204-205. 5. Sheikh M, Bruhl SR, Omer S, et al. Transmyocardial voyage of a temporary epicardial lead: an unusual long-term complication. Pacing Clin Electrophysiol. 2012;35(7): e185-e186. 6. Smith J, Tatoulis J. Right atrial perforation by a temporary epicardial pacing wire. Ann Thorac Surg. 1990;50(1): 141-142. 7. Meier DJ, Tamirisa KP, Eitzman DT. Ventricular tachycardia associated with transmyocardial migration of an epicardial pacing wire. Ann Thorac Surg. 2004;77(3): 1077-1079. 8. Worth PJ, Conklin P, Prince E, Singh AK. Migration of retained right ventricular epicardial pacing wire into the main pulmonary artery: a rare complication after heart surgery. J Thorac Cardiovasc Surg. 2011;142(3): e137-e138.
Downloaded from pch.sagepub.com at PENNSYLVANIA STATE UNIV on March 14, 2015
Transmyocardial Migration of a Temporary Epicardial Pacing Wire: A Pediatric Case Report
World Journal for Pediatric and Congenital Heart Surgery 2014, Vol. 5(2) 315-317 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135113515278 pch.sagepub.com
Marjorie A. Gayanilo, MD1, Eliot R. Rosenkranz MD1, Satinder K. Sandhu, MD1, and Richard E. Kardon, DO1
Abstract Transmyocardial migration of a retained temporary epicardial pacing wire has been rarely reported in adult patients after heart surgery. We present the case of a child in whom a temporary epicardial pacing wire was discovered incidentally in the right ventricular outflow tract one year after surgical repair of congenital heart disease. The pacing wire was subsequently extracted using the snare method during cardiac catheterization. Clinicians caring for patients after congenital heart surgery should be aware of this uncommon though potentially life-threatening complication. Keywords epicardial pacing wire, congenital heart disease, congenital heart surgery, postoperative care Submitted July 23, 2013; Accepted November 6, 2013.
Introduction The routine placement of temporary epicardial pacing wires is essential for the diagnosis and treatment of arrhythmias as well as optimizing hemodynamics after repair of congenital heart disease. The pacing wires are usually removed prior to discharge; however, if there is undue resistance, the wires are cut at the skin and allowed to retract into the pericardial sac. Complications arising from a retained epicardial wire have been reported in adults. We describe a pediatric case of a retained temporary epicardial pacing wire that migrated into the right ventricular outflow tract following congenital heart surgery.
Case Report Our patient is a 14-month-old child who was born with an aortic origin of the right pulmonary artery. The diagnosis was made by echocardiography after she was hospitalized at four weeks of age with progressive respiratory distress. At five weeks of age, she underwent surgical repair consisting of reimplantation of the right pulmonary artery into the main pulmonary artery. Intraoperatively pacing wires were simply placed on the epicardium of both the right atrial lateral wall and the right ventricular free wall and then subsequently secured to the surface with a 6-0 polypropylene suture. She had an uneventful postoperative course. Prior to hospital discharge, the pacing wires were cut at the level of the skin after an unsuccessful attempt to remove them with gentle traction.
The child subsequently developed right pulmonary artery stenosis and underwent transcatheter balloon dilation at four months of age. At routine follow-up evaluations, serial echocardiograms demonstrated Doppler evidence of significant residual right pulmonary artery stenosis. It seemed likely that reintervention would be necessary, and the hope was to postpone the procedure until it was feasible to place an endovascular stent at approximately one to two years of age. During a follow-up echocardiogram performed at 14 months of age, a puzzling linear density was discovered within the right ventricle that extended into the right ventricular outflow tract (Figure 1; Supplemental video). To help elucidate the identity of this finding, a chest radiograph was obtained and revealed superior migration of one of the retained pacing wires (Figure 2). After reviewing these studies, a plan was made for transcatheter removal of the migrated epicardial wire. The child was admitted to the hospital and underwent computed tomography with contrast to assess for associated infection. The scan showed no evidence of an abscess, and it confirmed our suspicion that a retained epicardial pacing wire
1
Department of Pediatric Cardiology, Holtz Children’s Hospital, University of Miami Miller School of Medicine, Miami, FL, USA Corresponding Author: Marjorie A. Gayanilo, Department of Pediatric Cardiology, Holtz Children’s Hospital, University of Miami Miller School of Medicine, Miami, FL 33136, USA. Email: [email protected]
Downloaded from pch.sagepub.com at PENNSYLVANIA STATE UNIV on March 14, 2015
316
World Journal for Pediatric and Congenital Heart Surgery 5(2)
Figure 1. Two-dimensional transthoracic echocardiogram (subcostal sagittal view) demonstrating a linear echodensity in the right ventricle and extending into the right ventricular outflow tract.
had eroded through the right ventricular wall and migrated superiorly into the right ventricular outflow tract (Figure 3). In the cardiac catheterization laboratory, a 5F Cook sheath was advanced to the main pulmonary artery with fluoroscopic guidance, and a 25-mm snare was used to retrieve a 4.6-cm segment of an epicardial pacing wire (Figure 4). Following the procedure, the child was observed overnight in the pediatric intensive care unit. Since the cardiac catheterization, she has had an uneventful course.
Discussion Over the past four decades, temporary epicardial pacing wires have been routinely placed in patients during cardiac surgery. Although these wires are usually removed, when resistance is encountered they are cut at the skin level and allowed to retract. Complications related to retained epicardial pacing wires have been well described by Del Nido and Goldman.1 One of these complications, transmyocardial migration of retained epicardial pacing wires, appears in the literature as only a small number of case reports. These reports all involve older adults and in the majority of cases have been discovered incidentally following coronary artery bypass procedures.2–8 In two instances, symptoms were directly attributed to the intracardiac migration of an epicardial pacing wire. In one patient, postoperative bleeding resulting in hypotension led to the diagnosis ten hours after heart surgery.6 Another patient developed ventricular tachycardia and cardiac arrest three years after a coronary artery bypass procedure.7 The incidental discovery by Worth et al8 of a retained pacing wire 24 years after its placement
Figure 2. Anteroposterior (A) and lateral (B) views of a chest x-ray showing an epicardial pacing wire that has migrated superiorly and is seen within the cardiac silhouette.
highlights the potential for very remote discovery of this complication. In this report, we present the case of a retained epicardial pacing wire that migrated into the right ventricular outflow tract one year after repair of congenital heart disease. Notably, the temporary wires had been secured to the epicardial surface of the atrium and the ventricle during the original surgical procedure but had not been inserted into, or passed through,
Downloaded from pch.sagepub.com at PENNSYLVANIA STATE UNIV on March 14, 2015
Gayanilo et al
317
Figure 4. Photograph of the retrieved epicardial pacing wire.
echodensity in the right ventricle and extending into the right ventricular outflow tract.
References Figure 3. Cardiac computed tomography demonstrates a linear opacity (arrow) within the right ventricle and extending into the right ventricular outflow tract.
the epicardium at the time of insertion. Although relatively uncommon, this particular complication has the potential for significant morbidity and therefore should prompt the development of novel lead technology and fixation techniques aimed at prevention. Those involved in caring for patients after congenital heart surgery should be aware of potential wire migration, allowing for prompt diagnosis and removal. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material The online video is available at http://wjpchs.sagepub.com/supplemental. Video 1. A ten-second clip of a two-dimensional transthoracic echocardiogram (subcostal sagittal view) demonstrating a linear
1. Del Nido P, Goldman BS. Temporary epicardial pacing after open heart surgery: complications and prevention. J Cardiac Surg. 1989; 4(1): 99-103. 2. Horng GS, Ashley E, Balsam L, Reitz B, Zamanian RT. Progressive dyspnea after CABG: complication of retained epicardial pacing wires. Ann Thorac Surg. 2008;86(4): 1352-1324. 3. Spellberg RD, Dobkin JE, Soleymani S. Intraoperative migration of operatively placed epicardial pacing leads. Ann Thorac Surg. 2012;93(5): 1713-1715. 4. Hong SN, Rosenzweig B, Crooke GA, Kronzon I, Srichai MB. Inside and out an epicardial lead gone array. Tex Heart Inst J. 2011;38(2): 204-205. 5. Sheikh M, Bruhl SR, Omer S, et al. Transmyocardial voyage of a temporary epicardial lead: an unusual long-term complication. Pacing Clin Electrophysiol. 2012;35(7): e185-e186. 6. Smith J, Tatoulis J. Right atrial perforation by a temporary epicardial pacing wire. Ann Thorac Surg. 1990;50(1): 141-142. 7. Meier DJ, Tamirisa KP, Eitzman DT. Ventricular tachycardia associated with transmyocardial migration of an epicardial pacing wire. Ann Thorac Surg. 2004;77(3): 1077-1079. 8. Worth PJ, Conklin P, Prince E, Singh AK. Migration of retained right ventricular epicardial pacing wire into the main pulmonary artery: a rare complication after heart surgery. J Thorac Cardiovasc Surg. 2011;142(3): e137-e138.
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