Complete transection of epicardial pacing lead
Cengiz C ¸eliker1, Farid Aliyev1*, Cengizhan Tu ¨rkog ˘lu1, and Ilhan Gunay2
1Department of Cardiology, Istanbul University, Institute of Cardiology, Division of Pacing and Electrophysiology, Haseki-
Fatih, Istanbul, Turkey; and2Department of Cardiovascular Surgery, Bas ¸kent University, Istanbul Hospital, Istanbul, Turkey
Received 14 February 2008; accepted after revision 12 August 2008
Herein, we presented a case of pregnancy associated complete transection of epicardial pacing lead.
A 36-year-old female patient was admitted to our hospital
for an evaluation of permanent pacemaker malfunction.
She has had open heart surgery for Ebstein anomaly and
mitral stenosis with implantation of bioprosthetic mitral
and tricuspid valves and a permanent epicardial pacemaker
for postoperative complete AV block ?10 years ago. During
the follow-up period, high pacing thresholds necessitated
implantation of second epicardial pacing lead. The patient
had an uneventful follow-up period, until sudden develop-
ment of fatigue and recurrent syncope, along with increase
in lead impedance and the absence of pacing capture during
the 7th month of pregnancy. At this stage lead fracture was
suggested, and due to prior operation, a new epicardial
pacing lead was introduced into the coronary venous
system via the right subclavian vein. Intermittent failure
of pacing capture was detected after uneventful delivery,
and the patient was referred to our institution for further
diagnostic and therapeutic considerations. Fluoroscopic
examination revealed complete transection of the epicar-
dial pacing lead (Figure 1). Pacemaker pocket and generator
were observed at the primary implantation site directly
under the incision line, located in the left iliac region of
anterior abdominal wall (not shown). Transthorasic and
trans-esophageal echocardiography revealed severe right
atrial enlargement and severe stenosis of the bioprosthetic
tricuspid valve, and the patient was referred for tricuspid
valve replacement and surgical implantation of a new
epicardial pacing lead.
Although, older epicardial electrodes were frequently
associated with a significant rate of increase in pacing
thresholds and sensing abnormalities in the past, recent
advances in lead technology, such as introduction of
steroid eluting leads, led to a considerable improvement
in these parameters.1,2Fracture and transection of epicar-
dial pacing leads are important problems encountered in
some of these patients. Complete transections are rarely
observed with endocardial leads and to our knowledge,
only two cases have been reported in the medical litera-
ture,3,4none of them related to pregnancy. On the other
hand, transection of epicardial pacing leads is not so infre-
quent, and is reported to occur secondary to growth in pedi-
atric population or as a result of trauma. The main place for
epicardial electrode fractures in pediatric population was
reported to be in the junction between pericardial cavity
and the abdominal wall, where the diaphragm works as a
hinge point during the intensive muscular activity.5In our
opinion, abdominal enlargement secondary to pregnancy,
led to the transection of the lead at this weakest point,
prone to fracture and transection, in our patient. Non-
traumatic complete transection of epicardial pacing leads
has not been reported in adult patients before. Most likely
in the present case, uterine and so abdominal enlargement
during pregnancy were extensive, leading to stretching
and subsequent transection of pacing lead, that traversed
the anterior abdominal wall, during the late pregnancy.
Preoperatively, positioning of the epicardial lead and
device pocket should be considered in female patients in
order to avoid lead stretch during pregnancy. It should be
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Europace Advance Access published September 4, 2008
noted that in our patient epicardial lead crossed the
abdominal wall from right side to the left, and this factor
resulted in significant stretching and subsequent transection
of the lead. This course of lead should be especially avoided
in female patients. Other peri-procedural methods, such as
cushioning of electrode with tissue at the above mentioned
weakest hinge point, and avoidance of fixation of lead to
pericardium were reported to be of value in the pediatric
population.5Although there is no data supporting this
point of view, we suggest that endocardial lead implantation
should be preferred in this patient population. In patients
undergoing epicardial lead implantation, importance of
the lead course discussed above should be kept in mind
and generator pocket should be placed in upper abdominal
wall or even in the sub-mammarian area, and placing it in
the lower abdominal wall, should be avoided.
Conflict of interest: none declared.
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seen on fluoroscopic examination in antero-posterior view (these
images were obtained following delivery).
Transection of epicardial pacing lead is apparently
C. C ¸eliker et al.
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