Europace Advance Access published online on September 26, 2008
Europace, doi:10.1093/europace/eun269
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CASE REPORT
Bizarre case of migration of a retained epicardial pacing wire
1 Department of Cardiac Surgery, University of Munich, Marchioninistr. 15, 81377 München, Germany; 2 Klinik Augustinum Munich, Munich, Germany
* Corresponding author. Tel: +49 89 7095 6462; fax: +49 89 7095 8873. E-mail address: gerd.juchem{at}med.uni-muenchen.de
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A 71-year-old woman, who had undergone mitral valve replacement procedure 2 years previously, presented with aortic and mitral prosthetic valve endocarditis. Preoperative examination demonstrated a wire-like structure coursing from the aortic bulb to the right carotid artery. The wire-like structure was removed during the mitral and aortic valve reoperation, and identified as an epicardial pacing wire, which was placed during the patients' first mitral valve operation. We suspect that the contaminated pacing wire migrated via the left atrium and left ventricle into the right carotid artery causing an infective endocarditis of the prosthetic mitral valve and the native aortic valve.
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We operated on a 71-year-old woman who suffered from calcified mitral valve stenosis. After excision of the anterior mitral leaflet and partial excision of the posterior mitral valve leaflet, we implanted a 25 mm pericardial tissue heart valve (Perimount Tissue Heart Valve, Edwards Lifesciences, USA). After an uneventful postoperative course and rehabilitation, the patient was discharged in good physical conditions. Two years later sudden vertigo, vomiting, and aphasia began to occur. Owing to suspicion of a stroke, she was hospitalized and routine examinations were performed. No pathological process was found in fluoroscopic imaging, cranial computed tomography, carotid vessels, or in the valve prosthesis. After spontaneous regression of the symptoms within 24 h, the diagnosis of transient ischaemic attack was postulated and the patient was anticoagulated. Two months later, the patient was hospitalized again due to dyspnoea, fever, tachycardia, diffuse abdominal pain, and leukocytosis. The transoesophageal echocardiography (TEE) showed an endocarditis of the mitral valve prostheses. Methicillin-resistent staphylococcus epidermidis (MRSE) was verified in three different blood cultures. The patient was treated for prosthetic valve endocarditis with intravenous vancomycin, gentamicin, and rifampicin and transferred to our unit for surgical replacement of the prosthetic valve. During preoperative examinations, a wire-like structure was detected by TEE in the ascending aorta, beginning at the aortic valve. The wire-like structure was also seen by duplex ultrasound of the carotid artery (Figure 1A), fluoroscopic imagine (Figure 1B), and computed tomography (Figure 1C).
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During open heart surgery, prosthetic mitral valve endocarditis with multiple vegetations (Figure 1D and E) was confirmed. The wire-like structure was identified as a migrated temporary pacing wire of 20 cm length (TME series bipolar, Osypka GmbH, Rheinfelden-Herten, Germany) (Figure 1F). This pacing wire was placed as a right atrial (initially located near the sinus node) temporary pacing wire at the patients first mitral valve operation. The ventricular temporary pacing wire was removed postoperatively without any difficulties. The atrial temporary pacing lead needed to be cut subcutaneously due to an insurmountable resistance during the extraction attempt. This situation might be caused by a substernal loop of the pacing wire either around native tissue or a sternal wire cerclage.
The tip of the wire was found in the aortic bulb (Figure 1G), the initially subcutaneous part was found in the right carotid artery. Owing to the primary location of the pacing wire near the sinus node, there are several potential ways of migration into the left heart system. A possible entrance for the tip of the pacing wire might be the right superior pulmonary vein or the roof of the left atrium (via the sinus transversus pericardii). If the initially subcutaneous part entered primary the left heart system, the most likely way would be a direct perforation of the left atrium. In any case, the contaminated pacing wire migrated via the left atrium and left ventricle into the right carotid artery. A direct perforation of the left ventricle or the aortic root is, in our opinion, unlikely, but cannot be excluded. A 20 mm vegetation of the aortic bulb and a perforation with damage to the non-coronary cusp of the aortic valve was also found. The wire was extracted and a replacement of the mitral and the aortic valve had to be performed. The patients' postoperative recovery was prolonged; she required intensive care for 4 days. The intravenous treatment with vancomycin and rifampicin continued until she was discharged (after 45 days in total). In the follow-up 8 months later, there was no recurrence of endocarditis and there was a good echocardiographical function of both bioprostheses.
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Temporary epicardial pacing wires are routinely used for the treatment of postoperative bradyarrhythmias after cardiac surgery and they usually get extracted before discharge.1
,2 The safety and efficacy of these pacing leads in the cardiac surgical routine have been generally accepted. Complications of epicardial temporary pacing wires placed during cardiac surgical procedures are rare.3,4 Sometimes, as in this case, extraction of the pacing wire is not possible and the wire is shortened and left subcutaneously. In our patient, the MRSE contaminated wire had migrated through the left heart into the carotid artery and caused infective endocarditis of the prosthetic mitral valve and the (native) aortic valve. |
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[1] Hodam RP, Starr A. Temporary postoperative epicardial pacing electrodes. Their value and management after open-heart surgery. Ann Thorac Surg (1969) 8:506–10.[Medline]
[2] Waldo AL, MacLean WA, Cooper TB, Kouchoukos NT, Karp RB. Use of temporarily placed epicardial atrial wire electrodes for the diagnosis and treatment of cardiac arrhythmias following open-heart surgery. J Thorac Cardiovasc Surg (1978) 76:500–5.[Abstract]
[3] Del Nido P, Goldman BS. Temporary epicardial pacing after open heart surgery: complications and prevention. J Card Surg (1989) 4:99–103.[CrossRef][Medline]
[4] Gentry WH, Hassan AA. Complications of retained epicardial pacing wires: an unusual bronchial foreign body. Ann Thorac Surg (1993) 56:1391–3.[Abstract]
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