Project Title

Complete Pacemaker Lead Fracture after a Theme Park Ride

Authors' Affiliations

(1) Muhammad Khalid MD, (2) Furqan Khattak MD, (1) Sathvika Gaddam MD, Vijay Ramu MD, FACC (2), (3) Vipul kumar Brahmbhatt Affiliations: 1: Department of Internal Medicine, Quillen College of Medicine, East Tennessee State University, Johnson city, TN 2: Department of Cardiology, East Tennessee State University, Johnson City TN 3: Mountain State Health Alliance, Johnson City, TN

Location

Clinch Mtn. Room 215

Start Date

4-5-2018 8:00 AM

End Date

4-5-2018 12:00 PM

Poster Number

151

Name of Project's Faculty Sponsor

Vijay Ramu

Faculty Sponsor's Department

Internal Medicine/Cardiology

Type

Poster: Competitive

Classification of First Author

Medical Resident or Clinical Fellow

Project's Category

Biomedical Case Study

Abstract Text

Fracture of a pacemaker lead is one of the most common causes of pacemaker malfunction. Lead fractures are seen in approximately 4 % of patients with pacemakers. We present a rare case of complete severance of the tip of a dual chamber pacemaker atrial lead.

A 62 years old male presented for a routine device check of his pacemaker, which was originally implanted in 2002 for sick sinus syndrome and had a generator change in 2010. Device check showed a dual chamber pacemaker with right atrial and right ventricular leads and a remaining battery life of 8.6 years. Patient was not pacemaker dependent. Ventricular lead showed normal sensing, impedance and pacing threshold. Atrial lead showed unusually high impedance of 2175 ohms and no capture on testing at voltages as high as 7.5 mV. Further evaluation was done due to abnormal atrial lead test. An EKG was obtained showing normal sinus rhythm and atrial pacing spikes with no capture. Chest X-ray revealed a complete severance and dislocation of the atrial lead tip and an intact ventricular lead. A detailed history was obtained, and patient denied any trauma to the chest or upper extremities, chest pain, shortness of breath, palpitations, syncope or presyncope. Upon further history, patient reported a recent visit to theme park and enjoying high thrill rides. On examination, there were no signs of trauma, erythema, swelling, warmth, drainage or erosion at implant site. The pacemaker setting was changed from DDDR to VVIR, with plans to cap the proximal port of the fractured lead and placing a new atrial lead.

Pacemaker lead fractures are reported with an incidence rate of 0.1 to 4.2 % per patient year [1]. The most common site of lead fracture is at the site of entry (40%) followed by between the entry site and generator (28%), close to the generator site (23%) and only (7%) are intravascular fractures [1]. Trauma and subclavian crush syndrome are the most commonly reported causes of pacemaker lead fractures. Pacemaker lead fracture due to physical exertion is an uncommon cause of lead malfunction [2]. Few cases have been reported of traumatic lead fracture due to the blunt chest trauma [3]. Patients with a lead fracture may present with symptoms of dizziness, syncope, chest discomfort, palpitations or, less commonly extra cardiac symptoms like hiccups or may completely be asymptomatic as seen in our patient. Diagnosis can be made by electrogram during device check, ECG and careful review of chest imaging such as chest x ray or fluoroscopy. Treatment is placement of a new lead with or without extraction of the fractured lead. This rare case of pacemaker lead fracture after a theme park ride indicates there may be a risk to pacemaker leads with high velocity amusement park rides which are becoming popular. This may have clinical implications such as a need for caution during amusement park visits and routine pacemaker interrogations after such visits especially in pacemaker dependent patients.

References:

1: Alt E, Völker R, Blömer H: Lead fracture in pacemaker patients. Thorac Cardiovasc Surg.1987, 35:101-4.10.1055/s-2007-1020206

2: ohm J: Displacement and fracture of pacemaker electrode during physical exertion. Report on three cases. Acta Med Scand.1972, 192:33-5.10.1111/j.0954-6820.1972.tb04774

3: Bőhm A1, Duray G, Kiss RG: Traumatic Pacemaker lead fracture. Emerg Med J.2013, 30:686.10.1136/emermed-2012-202090.

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Apr 5th, 8:00 AM Apr 5th, 12:00 PM

Complete Pacemaker Lead Fracture after a Theme Park Ride

Clinch Mtn. Room 215

Fracture of a pacemaker lead is one of the most common causes of pacemaker malfunction. Lead fractures are seen in approximately 4 % of patients with pacemakers. We present a rare case of complete severance of the tip of a dual chamber pacemaker atrial lead.

A 62 years old male presented for a routine device check of his pacemaker, which was originally implanted in 2002 for sick sinus syndrome and had a generator change in 2010. Device check showed a dual chamber pacemaker with right atrial and right ventricular leads and a remaining battery life of 8.6 years. Patient was not pacemaker dependent. Ventricular lead showed normal sensing, impedance and pacing threshold. Atrial lead showed unusually high impedance of 2175 ohms and no capture on testing at voltages as high as 7.5 mV. Further evaluation was done due to abnormal atrial lead test. An EKG was obtained showing normal sinus rhythm and atrial pacing spikes with no capture. Chest X-ray revealed a complete severance and dislocation of the atrial lead tip and an intact ventricular lead. A detailed history was obtained, and patient denied any trauma to the chest or upper extremities, chest pain, shortness of breath, palpitations, syncope or presyncope. Upon further history, patient reported a recent visit to theme park and enjoying high thrill rides. On examination, there were no signs of trauma, erythema, swelling, warmth, drainage or erosion at implant site. The pacemaker setting was changed from DDDR to VVIR, with plans to cap the proximal port of the fractured lead and placing a new atrial lead.

Pacemaker lead fractures are reported with an incidence rate of 0.1 to 4.2 % per patient year [1]. The most common site of lead fracture is at the site of entry (40%) followed by between the entry site and generator (28%), close to the generator site (23%) and only (7%) are intravascular fractures [1]. Trauma and subclavian crush syndrome are the most commonly reported causes of pacemaker lead fractures. Pacemaker lead fracture due to physical exertion is an uncommon cause of lead malfunction [2]. Few cases have been reported of traumatic lead fracture due to the blunt chest trauma [3]. Patients with a lead fracture may present with symptoms of dizziness, syncope, chest discomfort, palpitations or, less commonly extra cardiac symptoms like hiccups or may completely be asymptomatic as seen in our patient. Diagnosis can be made by electrogram during device check, ECG and careful review of chest imaging such as chest x ray or fluoroscopy. Treatment is placement of a new lead with or without extraction of the fractured lead. This rare case of pacemaker lead fracture after a theme park ride indicates there may be a risk to pacemaker leads with high velocity amusement park rides which are becoming popular. This may have clinical implications such as a need for caution during amusement park visits and routine pacemaker interrogations after such visits especially in pacemaker dependent patients.

References:

1: Alt E, Völker R, Blömer H: Lead fracture in pacemaker patients. Thorac Cardiovasc Surg.1987, 35:101-4.10.1055/s-2007-1020206

2: ohm J: Displacement and fracture of pacemaker electrode during physical exertion. Report on three cases. Acta Med Scand.1972, 192:33-5.10.1111/j.0954-6820.1972.tb04774

3: Bőhm A1, Duray G, Kiss RG: Traumatic Pacemaker lead fracture. Emerg Med J.2013, 30:686.10.1136/emermed-2012-202090.