A 63-year-old woman with a St. Jude Medical Riata 1570 right ventricular lead complained of intermittent hiccups 2 months after implant. Interrogation revealed elevated pacing threshold and diaphragmatic stimulation. Pacing and shock lead impedances remained stable. No inappropriate sensing was noted. Fluoroscopic examination of the lead revealed a thin radio-opaque wire seen between the 2 defibrillator coils away from the main body of the lead. After extraction, a tear in the insulation of the lead was noted allowing the inner wire to protrude. This case illustrates a novel mechanism of insulation failure without inappropriate sensing or impedance change.

MRI can be conducted safely in patients with CIEDs when done in a protocoled manner with appropriate supervision. DFT testing after MRI may not be necessary.

No abstract

Introduction: Management of infected CIEDs includes removal of the device with adjunctive antibiotic therapy. Temporary device management has historically consisted of a balloon-tipped temporary pacemaker (TPM). In recent years, TPMs with an externalized standard permanent pacing generator and an active fixation permanent pacing lead have become an alternative option to the balloon tipped pacemaker. These patients are typically kept in the hospital; however, this temporary pacing system is very secure, and with adequate social supports, these patients can be discharged. Methods: We reviewed data from patients who had CEID extraction between July 2012 and October 2021 at Oregon Health and Science University, and identified patients who were pacer dependent, underwent extraction for infection, and were discharged with an active fix TPM via the right internal jugular. Data for this study were collected prospectively in an IRB-approved clinical and research database for all patients undergoing lead extraction procedures. Results: A total of 14 individuals were identified between July 2012 and October 2021. Of the 14 patients identified, the majority were male (57.1%), had a median age of 71 years, and had systemic infections (92.9%). The mean length of hospitalization was 12 days, with a follow up visit occurring 5 days after discharge on average. One patient was lost to follow up following discharge with a plan for reimplantation at an outside hospital. The remaining 13 patients were seen weekly in pacer clinic for device and site checks. The total duration of TPM implantation ranged from 6 days to 153 days, with a mean of 36 days. There were no complications including systemic or local infection from TPM implantation or from reimplant of a new permanent device. Conclusions: Discharging patients with TPMs is a safe, cost saving, and well-tolerated option for pacemaker dependent individuals while they await reimplant of a new permanent device. The active fix TPM allows for antibiotics to be given at home, opens hospital beds, and relieves pressure to reimplant a permanent device as soon as possible.

Introduction: Venous stenosis is a late complication of the atrial switch (Mustard/ Senning) procedure seen in patients with transposition of the great arteries (D-TGA). Many atrial switch patients require cardiac implantable electronic devices (CIEDs) which further increases the incidence of venous stenosis. Stenosis of the superior limb of the systemic venous pathway (SLSVP) in the presence of CIED leads presents a management challenge. We propose a method for navigating SLSVP stenosis in atrial switch patients with CIEDs. Methods: The pulse generator and leads were removed using standard extraction techniques. Axillary access was retained via existing leads or new access was obtained. The interventional cardiology team, via groin access, performed stentangioplasty of the stenotic SLSVP. After stent deployment, the axillary access wire was snared from below, guided through the stent, and pulled into a long groin sheath. A sheath was then advanced over the axillary wire and into the groin sheath creating a path for passage of leads through the stent. New leads were advanced through the axillary sheath into the heart. Leads were secured using standard techniques. Results: All patients had a history of D-TGA and prior atrial switch procedures. In each case, there was stenosis of the SLSVP in the setting of a CIED lead. There were no immediate complications and there was no restenosis on follow-up. Conclusion: Post-atrial switch patients with CIEDs can develop stenosis of the SLSVP. A collaboration between electrophysiology and interventional cardiology can allow for device extraction, stent-angioplasty, and lead reimplantation to avoid "jailing" the leads.