Premature ventricular contraction–induced polymorphic ventricular tachycardia after leadless pacemaker implantation: A unique adverse effect of leadless pacing

Amin, Anish K.; Billakanty, Sreedhar R.; Chopra, Nagesh; Fu, Eugene Y.; Nichols, Allan J.; Kleman, James M.; Kidwell, Gregory A.

doi:10.1016/j.hrcr.2018.01.006

Cited by 14 publications

(22 citation statements)

References 6 publications

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“…Third, in some cases, patients were discharged within 24 hours. However, complications including early ventricular arrhythmias after placement of a MICRA have been reported . It is the opinion of the authors of this study that inpatient observation of higher risk patients is not only prudent but may be necessary for any number of reasons, including monitoring for the potential for postimplant ventricular arrhythmias.…”

Section: Discussionmentioning

confidence: 85%

Outcomes of Micra leadless pacemaker implantation with uninterrupted anticoagulation

Kiani

Black

Rao

et al. 2019

Cardiovasc electrophysiol

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Background: Implantation of the MICRA Leadless pacemaker requires the use of a 27French introducer, blunt delivery system and device fixation to the myocardium via nitinol tines. While prior studies have proven its safety, it is unclear whether performing this procedure with uninterrupted anticoagulation exposes patients to increased risks. We sought to investigate the feasibility and safety of continuing therapeutic anticoagulation during the periprocedural period. Methods:We evaluated all patients undergoing MICRA placement at our institution between April 2014 and August 2018 with complete follow-up data (n = 170).Patients were stratified into two groups: those on active anticoagulation (OAC, n = 26), defined as having an International normalized ratio >2.0 or having continued a direct oral anticoagulant, and those not anticoagulated (Off-OAC, n = 144). We evaluated for a composite outcome of all major complications, including access site complications and pericardial effusion.Results: OAC and Off-OAC groups had similar mean age (74 ± 13 vs 75 ± 13 years; P = .914). The OAC group had a nonsignificantly lower prevalence of end-stage renal disease (8% vs 17%; P = .375) and aspirin use (27% vs 47%; P = .131). Those in the OAC group were more likely to be on warfarin than those in the Off-OAC group (81% vs 30%; P < .001). The rate of the composite endpoint was similar between the OAC and Off-OAC groups (3.8 % vs 1.4%, respectively; P = .761). Length of stay was similar between groups (1.3 ± 2.6 vs 2.3 ± 3.4 days; P = 0.108).Conclusion: Continuation of therapeutic anticoagulation during MICRA implantation appears to be feasible, safe and associated with shorter hospitalization among appropriately selected individuals. K E Y W O R D SClinical: Implantable devicespacemaker-bradyarrhythmias

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Section: Discussionmentioning

confidence: 85%

Outcomes of Micra leadless pacemaker implantation with uninterrupted anticoagulation

Kiani

Black

Rao

et al. 2019

Cardiovasc electrophysiol

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“…4,5 Interestingly, we proceeded with more conservative management unlike the reported cases. [3][4][5] We agree with Amin et al 4 that myocardial local irritation as a result of multiple repositions might play a role in VAs, which in turn might explain a higher impedance and longer paced QTc. Despite the underlying mechanism remains a mystery, the relationship between inflammation and ventricular arrhythmias due to cytokine-mediated myocardial remodeling has been previously published and could justify the efficacy of a conservative strategy.…”

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confidence: 90%

“…Our hypothesis was that long QT was acquired due to myocardial inflammatory damage and intravenous steroids and overstimulation were empirically used in the treatment leading to a resolution of repolarization abnormalities and premature ventricular contractions ( Figure 1C).The association of Micra implantation with the development of malignant VAs has been reported in three cases to the date, as summarized in supplementary table-1. [3][4][5] In all cases, a temporal connection between the leadless PM implantation and the development of the VAs was established, as patients did not suffer before from either premature ventricular contractions or ventricular tachycardia, and in all of the cases the paced beat played a key role in their development. 4,5 Interestingly, we proceeded with more conservative management unlike the reported cases.…”

mentioning

confidence: 96%

“…[3][4][5] In all cases, a temporal connection between the leadless PM implantation and the development of the VAs was established, as patients did not suffer before from either premature ventricular contractions or ventricular tachycardia, and in all of the cases the paced beat played a key role in their development. 4,5 Interestingly, we proceeded with more conservative management unlike the reported cases. [3][4][5] We agree with Amin et al 4 that myocardial local irritation as a result of multiple repositions might play a role in VAs, which in turn might explain a higher impedance and longer paced QTc.…”

mentioning

confidence: 96%

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Ventricular arrhythmias after leadless pacemaker implantation, a case report and systematic review of the literature

Alonso

Sandín‐Fuentes

García‐Granja

et al. 2019

Cardiovasc electrophysiol

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Disclosures: Dr. J. Rubio has served as a proctor for Medtronic. Other authors: No disclosures.Leadless pacemakers emerged as a means to decrease the incidence of lead and device-related complications of traditional PMs. Micra is the leadless PM most used worldwide. Its safety was addressed on the Micra transcatheter pacing study trial with a reported success rate of 100% and has been recently confirmed in an updated of the performance of Micra in the real-world setting. 1,2 However, in the first report in 2015 among 30 adverse events in 26 patients there were two ventricular tachycardia and one ventricular fibrillation, none of them resulting in death or reoperation. Furthermore, in the update in a real-world setting, there were 13 sudden cardiac deaths among 1801 implants during a mean follow-up of 6.8 ± 6.9 months. 1,2 No consistent explanation has been proposed but ventricular arrhythmias (VA) may have a causal relationship.In the basis of our experience we present a case of an aborted sudden cardiac death due to polymorphic ventricular tachycardia (PVMT) after Micra implant in the face of an acquired long QT ( Figure 1A), telemetry showed that the mechanism of the PMVT was an "R-on-T" phenomenon after a short-long-short sequence triggered by premature ventricular contractions ( Figure 1B). Our hypothesis was that long QT was acquired due to myocardial inflammatory damage and intravenous steroids and overstimulation were empirically used in the treatment leading to a resolution of repolarization abnormalities and premature ventricular contractions ( Figure 1C).The association of Micra implantation with the development of malignant VAs has been reported in three cases to the date, as summarized in supplementary table-1. [3][4][5] In all cases, a temporal connection between the leadless PM implantation and the development of the VAs was established, as patients did not suffer before from either premature ventricular contractions or ventricular tachycardia, and in all of the cases the paced beat played a key role in their development. 4,5 Interestingly, we proceeded with more conservative management unlike the reported cases. [3][4][5] We agree with Amin et al 4 that myocardial local irritation as a result of multiple repositions might play a role in VAs, which in turn might explain a higher impedance and longer paced QTc. Despite the underlying mechanism remains a mystery, the relationship between inflammation and ventricular arrhythmias due to cytokine-mediated myocardial remodeling has been previously published and could justify the efficacy of a conservative strategy. 6 On the basis of the facts address above, we would like to underline the possible proarrhythmic effect of leadless PM implant due to traumatic myocardial inflammation. The case and the systematic review highlight how immediate ECG and short term monitoring after the procedure could be a simple strategy to early identify high-risk repolarization abnormalities that may benefit from conservative management due to its transitory nature. Long-term ...

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“…The system was extracted successfully, revised with a new device of the same type successfully implanted at a different position in the right ventricle, and the VT resolved. The pro-arrhythmic effect of the leadless pacemaker remains to be elucidated, but it may involve the irritation of the right-ventricular myocardium at the site of implantation [27].…”

Section: Other Safety Issuesmentioning

confidence: 99%

Leadless Pacemakers

Magnusson¹,

Pergolizzi²,

LeQuang³

2019

Cardiac Pacing and Monitoring - New Methods, Modern Devices

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Leadless or transcatheter pacemakers have recently been introduced to market with important benefits and some limitations. Implanted entirely within the right ventricle, these devices eliminate the need for transvenous pacing leads and pacemaker pockets and thus reduce the risk of infections and lead-related problems. Currently, they offer only VVI/R pacing and they cannot provide atrial sensing, antitachycardia pacing, or AV synchrony. They offer a number of features (such as rate response) and electrogram storage, albeit more limited than in a transvenous system. Real-world clinical data are needed to better comment on projected battery life, which manufacturers suggest will be at least equivalent to transvenous devices. Extracting an implanted leadless pacemaker remains a challenge, although proprietary snare and removal systems are available. However, a leadless pacemaker at end of service may be programmed to OOO and left in place; a revised device may be implanted adjacent. These innovative new devices may have important uses in special populations. Initial data on implant success and adverse events are favorable. Currently, there are two leadless pacemakers available: the Micra™ device by Medtronic and the Nanostim™ device by Abbott (formerly St. Jude Medical).

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Premature ventricular contraction–induced polymorphic ventricular tachycardia after leadless pacemaker implantation: A unique adverse effect of leadless pacing

Cited by 14 publications

References 6 publications

Outcomes of Micra leadless pacemaker implantation with uninterrupted anticoagulation

Outcomes of Micra leadless pacemaker implantation with uninterrupted anticoagulation

Ventricular arrhythmias after leadless pacemaker implantation, a case report and systematic review of the literature

Leadless Pacemakers

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