Discovery and Management of Diaphragmatic Hernia Related to Abandoned Epicardial Pacemaker Wires in a Pregnant Woman with {S,L,L} Transposition of the Great Arteries

Abstract

Epicardial pacemaker leads placed during childhood are often not removed when transvenous systems are placed later in life. The risk of complications related to retained pacemaker leads and generators is not clear but is generally considered low. We report the case of a 23-year-old pregnant woman who presented with left upper quadrant pain at 20 weeks gestation. The patient was born with {S,L,L} transposition of the great arteries and had high-grade conduction disease in infancy compelling epicardial pacemaker placement. A standard transvenous pacemaker was placed at age 9 years, without removal of the epicardial system. The patient’s abdominal pain was attributed to herniation of abdominal contents through a diaphragmatic defect at the site of the abandoned epicardial pacing wire. Her pain improved spontaneously but worsened later in pregnancy leading to repair of the diaphragmatic hernia via anterolateral thoracotomy at 30 weeks gestation. The procedure was well tolerated by mother and fetus. At 38 3/7 weeks gestation, the patient underwent uneventful delivery by cesarean section for breech presentation. This case illustrates the importance of multidisciplinary collaboration in the care of women with congenital heart disease.

Delayed granulomatous reaction and cutaneous fistula induced by retained electrodes from a cardiac pacemaker in a child

“…Another rare complication was published by Benson regarding a pregnant woman with transposition of the great arteries who developed an iatrogenic diaphragmatic hernia that was located at the point where her epicardial pacing wires crossed the diaphragm. Fortunately, multidisciplinary management facilitated a successful repair of the diaphragmatic defect without any relevant consequences …”

“…In the case of permanent epicardial pacemakers that were placed during childhood, such as our patient's, it has not been established if a complete removal, including the leads, is advisable when transvenous systems are placed later in life. The risk of complications related to the retained epicardial leads is generally considered to be low . In contrast, other authors recommend removing the epicardial wires when they are no longer needed due to the low risk of the procedure when compared to the potential benefits .…”

“…3 Retained epicardial leads can also lead to long-term consequences such as lead dislodgment, diaphragmatic hernia, venous thrombosis, muscle stimulation, and skin lesions. 7 In the case of dermatologic findings, it should be noted that cutaneous erosions, local infections, fistulas, and granulomatous reactions close to pacemaker scars should lead doctors to consider the presence of an underlying abandoned lead. 2,3 F I G U R E 1 Clinical photograph shows erythematous swelling in the epigastrium, where a nodular and ulcerated lesion can be appreciated (arrow).…”

“…The risk of complications related to the retained epicardial leads is generally considered to be low. 7 In contrast, other authors recommend removing the epicardial wires when they are no longer needed due to the low risk of the procedure when compared to the potential benefits. 9 As a result, there is not a clear consensus and this decision often requires an individual assessment.…”

The catastrophic journey of a retained temporary epicardial pacemaker wire leading toEnterococcus faecalisendocarditis and subsequent stroke

“…In 2012, another case of migration occurred where the lead travelled from the right ventricular myocardium into the pulmonary artery in a patient who had successfully undergone CABG 13 years prior 17. Another case involved a pregnant woman reporting of abdominal pain that was later attributed to herniation of abdominal contents through a diaphragmatic defect at the site of the abandoned epicardial pacing wire 18. Lastly, a case with devastating complications involved a young man who had retained an epicardial pacing wire after infant repair of an atrioventricular septal defect; this wire was found to have subsequently compressed the left anterior descending artery, leading to his cardiac arrest and death 19…”