Electrical Nightmare: a Case Electrical Nightmare: a Case of Complete Heart Block, of Complete Heart Block, Dilated Cardiomyopathy, Dilated Cardiomyopathy,

Infections, Difficult Venous Infections, Difficult Venous AccessAccess

Sergio L. Pinski, MDCleveland Clinic Florida, Weston, FL

58 y/o man first seen in June 2004 for consideration for biventricular pacing in CHF NYHA III. On good medical Tx

Heart failure symptoms for a year In Feb 2004 dual-chamber PM for

complete heart block in Indiana No-obstructive coronary artery disease,

LVEF 25%, moderate mitral regurgitation

Diabetes, retinopathy, nephropathy, proteinuria, creatinine of 4.2, peripheral vascular disease

MDT 4574 in atrium, MDT 4092 in RV apex. Good thresholds, no escape.

What would you do?What would you do?

A. Schedule for CRT-DB. Schedule for CRT-PC. Schedule for ICDD. Order a new echocardiogram to

evaluate LV dyssynchronyE. Order left upper extremity venogramF. Something elseG. Nothing, all futile with severe renal

failure

Initial upgradeInitial upgrade

July 2004. Moderate stenosis of left subclavian

vein Difficult CS cannulation Lateral vein with very acute take-off

and 2 bends. Cannulated with wire, but lead would

not progress We also tried a small anterolateral vein,

Easytrak I lead did not progress even after cutting tines.

What would you do?What would you do?

A. Place ICD lead in apex, dual-chamber ICD

B. Place ICD lead in apex, place CRT-D device, plug LV port, reattempt transvenous approach

C. Place ICD lead in apex, place CRT-D device, plug LV port, refer for epicardial lead placement

D. None of the above

Bifocal RV pacingBifocal RV pacing

We then placed a Gore-coated defibrillation lead in the mid RV septum.

We connected the old apical pacing lead to the RV port and the defibrillation lead to the LV port, to achieve bifocal RV pacing.

Appropriate function.

Subsequent courseSubsequent course Clinical improvement, creatinine 3.6 Oct 04 plan to construct AV fistula. Insurance problems. Lost to F/U. Presents in Feb 05 with uremia,

hyperkalemia, volume overload Started on dialysis through a right

subclavian catheter He improves In March and April 05, referred again for

vascular access, but misses appointment

InfectionInfection In June 05 he presents with fever, redness

around the dialysis catheter in right subclavian vein.

Methicillin-sensitive Staph aureus bacteremia Catheter moved first right femoral, then left

IJ vein Vancomycin plus levofloxacin, then oxacillin

plus gentamicin plus rifampicin Persistent fever, positive blood cultures for 7

days. TEE (suboptimal) no vegetations Leukocyte indium scan with no cardiac uptake ID recommends ICD extraction

What would you do?What would you do?

A. Continue ATBB. Remove system in left side, place new

system from right side in same sessionC. Remove system in left side, temporary

wire until blood cultures persistently negative, then new system from right side

D. Remove system, implant epicardial system in the same setting

E. Remove system, try to elicit stable escape rhythm with isoproterenol

F. None of the above

What type of temporary What type of temporary wire?wire?A. Standard temporary ventricular pacing

wireB. Active-fixation temporary ventricular

pacing wireC. Active-fixation permanent ventricular

pacing wireD. Some type of dual-chamber temporary

pacing E. Other

ICD extractionICD extraction June 29, 2005 Temporary wire from left femoral vein Pocket clean ICD lead removed with locking stylet and

strong sutures RV apical lead released with locking stylet

and strong sutures, but became entrapped in innominate vein, released with Laser sheath

RA lead with heavy adhesions, required lasing all the way down to the RA

Temporary pacemakerTemporary pacemaker

Right infraclavicular pocket Axillary vein, active-fixation leads to RA

appendage and RV septum Leads connected to two extenders,

tunneled and exteriorized below the right nipple, secured with sleeves, attached to an external permanent pacemaker

Distal loops of leads, proximal loop of extender encased in a Dacron pouch

Subsequent courseSubsequent course

Discharged in 3 days, to complete 4 weeks of ATB

Blood cultures became negative Lead culture negative

More complicationsMore complications In early July construction of right arm AV

fistula Tunneled dialysis catheter in left subclavian

vein July, 29 2005 falls and suffers left hip Fx Left intertrochanteric open reduction and

internal fixation Sent to rehab facility, back to us because of

unfamiliarity with externalized pacemaker In Sep 2005, right AV fistula not mature,

dialysis via left subclavian catheter

Infection November 05Infection November 05

Redness and discharge around the exit site of the extenders in the right chest

No fever. No leukocytosis. Blood cultures negative.

AV fistula still not working well, low flow. Dialysis via Quinton catheter in left subclavian vein

What would you do?What would you do?

A. Treat medicallyB. Request moving of dialysis catheter,

then implant ICD or CRT-D from left side.

C. Remove current leads, place new leads from right side

D. Try to salvage present leads, implant pacemaker on right side

E. Send for epicardial system (PM, ICD, CRT-P, CRT-D)

F. None of the above

New Pacemaker November New Pacemaker November 05 (138 days of temporary 05 (138 days of temporary pacing)pacing) Temporary pacer from right femoral vein

Pocket entered, dacron pouch partially fibrosed. No signs of infection.

Extenders dissected free, cut and pulled from below. Atrial lead with good function Ventricular lead had good function, but with a

circumferential breach in the insulation Access right axillary vein New lead to RV outflow tract Failed lead pulled out with simple traction New dual-chamber PM in right infraclavicular pocket Subcostal area debrided. Left open sinus to heal by

secondary intention

Subsequent courseSubsequent course 1 dose of vancomycin Culture from extender yeast, coagulase-

negative Staphylococcus Subcostal sinus healed with local

treatment By December 2005, dialysis via AV fistula Tunneled catheter removed in January

2006 He develops progressive heart failure,

despite aggressive dialysis in July 2006

What would you do?What would you do?

A. Complete new CRT-D from left sideB. Upgrade to CRT-D from right sideC. Upgrade to CRT-P from right sideD. Try to add LV lead from left side,

then tunnel to right pocket for CRT-PE. Continue medical treatment,

ultrafiltration

Upgrade to CRT-P August Upgrade to CRT-P August 0606 Difficult left axillary vein access Coronary sinus cannulated Larger lead (Easytrak 3) delivered to

posterolateral vein- Good thresholds Lead tunneled to right pocket Small pneumothorax, chest tube for 48

hours Immediate improvement in heart failure

symptoms

10 month follow-up10 month follow-up

NYHA I No readmissions Dialysis 3 days a week