(Chest. 1999;116:1133-1134.)
© 1999
American College of Chest Physicians
Right Pneumothorax Resulting From an Endocardial Screw-In Atrial Lead*
Wan-Jing Ho, MD;
Chi-Tai Kuo, MD and
Kuo-Hong Lin, MD
*
From Department of Cardiology, Chang Gung University, and Chang Gung Memorial Hospital-Taipei, Taiwan.
Correspondence to: Chi-Tai Kuo, MD, Chang Gung Memorial Hospital, 199 Tun Hwa N. Rd, Taipei, 105, Taiwan; e-mail: chitai{at}adm cgmh.com.tw
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Abstract
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Right pneumothorax complicated by an endocardial atrial lead has
never been reported. Herein, we report on a small-build 79-year-old
Taiwanese woman who suffered from complete AV block and underwent
dual-chamber permanent pacemaker implantation. An active fixation
screw-in atrial lead was chosen. The procedure was complicated by right
pneumothorax associated with atrial perforation. Since simple
measurements of the implantation parameters could not be used to
predict the occurrence of perforation, great caution should be taken in
to avoid overscrewing the atrial lead, and in scrutinizing the
penetration depth of the helix of the lead under
fluoroscopy.
Key Words: atrial perforation • permanent pacemaker • pneumothorax • screw-in atrial lead
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Introduction
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An endocardial atrial screw-in lead was introduced to the
market in 1980. A few complications have been reported, such as
lead dislodgment, lead fracture, acute pericarditis, and cardiac
perforation.1
2
However, right pneumothorax caused by an
endocardial atrial lead has never been reported. We present a case of
right pneumothorax induced by an active screw-in atrial lead in a
small-build Taiwanese woman.
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Case Report
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A 79-year-old woman with a body weight of 51 kg and body
length of 140 cm was admitted to our hospital for dizziness and
recurrent syncope on December 12, 1996, without any previous systemic
disease.
The ECG on admission showed a complete AV block with a junctional
escape rhythm of 42 beats/min. The chest radiograph was normal.
Electrophysiologic study showed intra-Hisian block. A permanent
pacemaker implantation via left subclavian approach was performed
subsequently. The ventricular lead (Selute 4285-59cm;
Guidant; St. Paul, MN) was introduced first, followed by
insertion of a screw-in atrial lead (CapSule atrial J 4568-53cm;
Medtronic; Minneapolis, MN) smoothly without any difficulty (Fig 1
). Atrial pacing threshold was 1.3 V, pacing impedance was 650 ohms, and
P-wave amplitude was 3.3 mV. Ventricular pacing threshold was 0.4 V,
pacing impedance was 960 ohms, and R-wave amplitude was 11.8 mV. A
generator (Vigor DR model 1230; Guidant) was then connected, and the
ECG showed normal dual-chamber pacing. Unfortunately, the patient
started to complain of difficulty in breathing 4 h later.
Auscultation revealed coarse crackles over the left chest with
diminished breath sounds on the right. ECG revealed an
intermittent loss of atrial sensing. Therefore, the pacemaker was
immediately programmed to the VVIR pacing mode. Tube thoracotomy
drainage was instituted immediately after the confirmation of right
pneumothorax by chest radiograph (Fig 2
). The symptoms improved substantially after the procedure.
Transthoracic two-dimensional echocardiogram showed no evidence of
significant pericardial effusion, and the atrial lead could not be well
demonstrated. Transesophageal two-dimensional echocardiogram also
revealed no evidence of extravasation. The cinefluoroscopy in 30°
left anterior oblique view clearly showed the extrusion of the screw-in
atrial lead from the right atrium to the right lung (Fig 3
). An atrial lead replacement was done 2 days later. Under local
anesthesia, the screw-in atrial lead was unscrewed first and withdrawn
carefully. ECG and BP monitoring were continued. The pericardiocentesis
kit and echocardiography equipment were all on standby. Another steroid
eluting, tined, hook-on bipolar endocardial lead (CapSule 5524M-53cm;
Medtronic) was implanted from the same venous access
uneventfully. The atrial pacing threshold was 0.8 V, pacing impedance
was 840 ohms, and P-wave amplitude was 3.3 mV. The pacing and sensing
parameters of the previously inserted ventricular lead remained
unchanged as before. The chest tube was removed on the ninth day of
hospitalization. The patient was discharged the following day with ECG
showing normal dual-chamber pacing.
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Discussion
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Atrial lead implantation is needed for more physiologic pacing,
but the complications are still more frequent as compared to a
ventricular lead. Implanting an atrial lead is sometimes difficult, and
dislodgment is another common problem.3
To overcome these
problems, active fixation mechanisms have been developed. Greene et
al described that acute pericarditis developed in 4.9% of the
patients, especially when the lead was placed in the lateral and
anterolateral wall of the right atrium.2
A few cases
involving atrial wall perforation by an endocardial pacing lead have
been described previously.4
5
A recent publication by the
Mayo Clinic showed a 2.4% rate of acute lead-related complications,
ie, perforation, microdislodgment, and
pericarditis.6
Pneumothorax is common during subclavian vein puncture. However, we
present this case in which pneumothorax was induced by the endocardial
atrial lead. Several risk factors can be attributed to the implantation
technique and lead design, including overscrewing, distal stiffness,
and penetration depth of the helix of the lead. Since the lead screw
itself has no electrical conductance property, its main function is
mechanical support and stability. It does not serve as a discriminator
in identifying cases when perforation occurs. Therefore, the
implantation parameters could not be used to predict the occurrence of
perforation.6
Great caution must be taken when implanting an atrial screw-in
lead, particularly into the anatomically thin right atrial free wall.
We should avoid overscrewing, especially when positioning the lead in
the lateral or anterolateral wall, without compromising the lead
stability. The patient reported herein was a Taiwanese woman having a
relatively small build. Whether the right atrial wall is thinner in
Orientals than in whites remains to be determined.
In conclusion, atrial screw-in lead placement can still cause
right pneumothorax under the current design in an Oriental patient.
Thus, for placement of an atrial active fixation screw-in lead, we
strongly recommend using great caution to avoid overscrewing the lead,
and limiting the penetration depth of the helix of the lead under
fluoroscopy. However, most centers now prefer the hook-on atrial leads
used in the right atrial appendages instead of the atrial screw-in
leads.
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Footnotes
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Abbreviations: AV = atrioventricular; ECG =
electrocardiogram
Received for publication January 20, 1999.
Accepted for publication May 11, 1999.
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References
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Porsonnet, V (1995) The retention wire fix. PACE 18,955-957
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Greene, TO, Portnow, AS, Huang, SKS (1994) Acute pericarditis resulting from an endocardial active fixation screw-in atrial lead. PACE 17,21-25
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Markewitz, A, Wenke, K, Weinhold, C (1988) Reliability of atrial screw-in lead. PACE 11,1777-1783
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Smith, JA, Tatoulis, J (1990) Right atrial perforation by a temporary epicardial pacing wire. Ann Thorac Surg 50,141-142[Abstract]
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Nooten, GV, Verbeet, T, Deuvaert, FE (1990) Atrial perforation by a screw-in electrode via a left superior vena cava. Am Heart J 119,1439-1440[Medline]
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Glikson, M, Von Feldt, LK, Suman, VJ, et al (1994) Clinical surveillance of an active fixation, bipolar, polyurethane insulated pacing lead: Part 1. The atrial lead. PACE 17,1399-1404
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Abstract
Introduction
