Cardiac strangulation after epicardial pacing: the importance of non-specific symptoms and a low index of suspicion

Abstract

Cardiac strangulation is a rare and potentially deadly complication of epicardial pacemaker implantation. A young boy presenting with chest pain and tiredness almost 7 years after pacemaker implantation was found to have cardiac strangulation. Literature review revealed 22 cases reported to date with a worrying rise in the number of reports over the past 3 years. Strangulation is associated with implantation of leads at a young age and appears to be related to somatic growth. Serial assessment with chest X-ray and echocardiogram is recommended, at least until full adult growth is attained with further coronary artery imaging reserved for symptoms or suspicious echocardiographic findings. If cardiac strangulation is diagnosed prompt replacement of the offending system is needed.

Epicardial Pacemaker Causing Cardiac Strangulation

“…Cardiac Strangulation by epicardial leads causes symptoms due to external obstruction of structures including the atrioventricular (AV) valves, coronary arteries or the great arteries resulting in heart failure and/or ischaemia [ 1 ]. Symptoms can be absent, mild or severe with reported cases of ventricular arrhythmia and cardiac arrest [ 2 ]. Symptoms may only become apparent in times of increased myocardial demand or stress such as exercise or on induction of anaesthesia [ 3 ].…”

“…Symptoms may only become apparent in times of increased myocardial demand or stress such as exercise or on induction of anaesthesia [ 3 ]. Strangulation incidence is likely under-reported, factors including lack of awareness and the need for a detailed post-mortem being potential confounders [ 2 ].…”

“…Surgical technique as to placement of excess lead length is variable [ 2 ] and different strategies have been advocated for the excess lead, the lead being placed in the anterior mediastinum outside the pericardium or anterior to the myocardium [ 4 ], or the diaphragmatic surface of the pericardium [ 1 , 3 , 5 ]. Careful attention to coronary anatomy and avoidance of the Left anterior Descending (LAD) artery is particularly important when placing leads anteriorly [ 1 ].…”

A case of cardiac strangulation following epicardial pacemaker implantation in an adult: a case report

“… 5 As the child grows, the EP leads strangle the heart, causing dizziness, syncope, arrhythmia, angina pectoris, myocardial infarction, heart failure, valvular diseases, and sudden cardiac death, but non-specific or asymptomatic cases have also been reported. 2 , 6 Cardiac strangulation is difficult to diagnose because of the small number of cases reported and the lack of definitive diagnostic algorithms or criteria, which may contribute to the variability in its reported prevalence.…”