Pacemaker Lead Placement via Transmural Approach in an Adult With Palliated Single Ventricle Heart Disease

Given the lack of systemic venous return to the heart, palliated single ventricle patients frequently require epicardial pacemaker implantation for management of dysrhythmias including sinus node dysfunction, atrial arrhythmias, and heart block. Repeated device hardware replacement, frequently required due to high lead thresholds or other device failure, is a challenging and significant problem for this population. 3-dimensional imaging can assist in delineating the cardiac anatomy allowing for novel approaches to intervention. We review a patient with extracardiac Fontan circulation who underwent placement of an endocardial atrial pacemaker lead via a transmural approach with a 3D-printed model used for procedural guidance.

732 TEE role in patients selection for transcatheter edge to edge tricuspid repair

Aims The natural history of tricuspid valve (TV) regurgitation is characterized by dismal prognosis and high in-hospital mortality when treated with isolated TV surgery. Although the anatomy and the imaging of the TV are very challenging, the edge-to-edge repair with the TriClip (Abbott Vascular, Santa Clara, CA) showed promising results. We report preliminary results of our experience with the TriClip System in a cohort of ‘real life’ patients with functional tricuspid regurgitation (TR). Methods and results From January to September 2021, 30 consecutive patients with severe TR has been screened, 8 underwent transcatheter TriClip repair. The anatomical feasibility was established according to a complete transesophageal echocardiogram (TEE) and a dedicated CT scan for the right cardiac chambers. All the echocardiographic projections focused on right ventricle were used during the procedure, with the aim of optimizing the visualization of the catheters and device with respect to the anatomical structures of the tricuspid valve complex. The procedure was conducted under general anesthesia, guided by TEE and fluoroscopy. In-hospital and 30-day clinical and echocardiographic outcomes were recorded. The annulus septo-lateral diameter was enlarged in all cases, and functional TR was present in all patients. In two patients, the pacemaker lead interfered with leaflets coaptation. TR jet was predominantly central. The implant and procedural success were achieved in all cases, implanting one device in five patients and two in three patients. The final TR grade was 2+ in four patients and and 1+ in the others. All patients were extubated in the catheterization laboratory. There were no procedural or in-hospital adverse events. At 30-day follow-up, we observed significant improvement in clinical and echocardiographic outcomes. Conclusions In our experience, 26% of screened patients were selected for the procedure. Favourable anatomical findings for the TV edge-to-edge repair were the following: moderate leaflet tethering (coaptation depth <10 mm); large annulus but with small coaptation gap (<7 mm); antero-septal or postero-septal jet location; commissural jet; small right ventricular dimensions; pacemaker lead with no leaflet tethering. The best transcatheter approach consists of obliterating the antero-septal coaptation rim for a more favourable angle between the inferior vena cava and valvular plane. High-quality TEE imaging during the procedure is required for obtaining procedural success. Patient selection and tricuspid valve anatomy characterization with TEE and cardiac CT scan is critical for procedural success and clinical improvements.

Mycobacterium fortuitum pacemaker infection: A case report

Mycobacterium fortuitum is a rapidly growing mycobacterium, ubiquitous in soil and water, but it is an uncommon cause of infections in immunocompetent hosts. Cardiac device infections and bloodstream infections due to non-tuberculous mycobacteria are rare. We present the case of an 85-year-old patient with infective endocarditis and pacemaker lead infection secondary to M. fortuitum.

Severe pacemaker pocket infection during the COVID-19 pandemic, transvenous lead removal

Introduction: The estimated infection rate after permanent endocardial lead implantation is between 1% and 2%. Pacemaker lead endocarditis is treated with total removal of the infected device and proper antibiotics. In this case report, we present a patient with delayed diagnosis and treatment due to the COVID-19 outbreak. Case Report: An 88-year-old, pacemaker dependent woman with diagnosed pacemaker pocket infection was admitted to the University Cardiovascular institute. The patient had a prolonged follow-up time due to the COVID-19 outbreak. She missed her routine checkup and came to her local hospital when the generator had already protruded completely, to the point where she held it in her own hand. Transthoracic echocardiogram showed possible vegetations on the lead. Transesophageal echocardiography was not performed due to the COVID-19 pandemic. On the day after the admission the patient underwent transvenous removal of the pacemaker lead using a 9 French gauge rotational extraction sheathe (Cook Medical). The extracted lead was covered in a thin layer of vegetations. Further follow-ups showed good recovery with no complications. Conclusions: A case showing delayed treatment of pacemaker pocket infection, due to delayed follow-up time during the COVID-19 pandemic. This patient underwent successful transvenous removal of the infected pacemaker lead, along with adequate antibiotic therapy, which has proven to be the most effective method of treating cardiac device-related endocarditis.

Pacemaker Lead Migration and Ventricular Perforation in a Patient Presenting with Chest Pain

Case Presentation: We describe a middle-age male with a past medical history of second-degree atrioventricular block type II status post permanent pacemaker placement the day prior who presented to the emergency department complaining of chest pain. Electrocardiography showed a non-paced ventricular rhythm. Chest radiograph showed the ventricular pacemaker lead located distally overlying the right ventricle apical area. On further investigation, chest computed tomography showed a perforation of the ventricular wall by the pacemaker lead prompting urgent intervention by the cardiothoracic surgery team for lead replacement and right ventricular repair. Discussion: Our case illustrates the importance of timely recognition of a perforated pacemaker lead in a patient presenting with chest pain after device implantation. We additionally describe the risk factors for ventricular perforation, initial clinical presentation, and management approach.