Pacemaker Lead dislodgement

[silwin]

Hi - my husband had a dual chamber pacemaker implanted 4 days ago for Sick Sinus Syndrome (with 2 to 4 second pauses) and Atrial Fibrillation. After the procedure, the surgeon indicated that it was difficult to position the atrial lead due to mild cardiomegaly and it dislodged within the first 24 hours. The electrophysiologist deactivated the atrial lead explaining that it targeted Atrial Fib and was primarily for quality of life, whereas the ventricle lead targeted bradycardia and pauses. He recommended that my husband have the atrial lead repositioned. He indicated that the surgeon would determine during the procedure whether to use an unfixed lead (as was used the first time) or whether to try a fixed lead, and that there is a chance the lead will dislodge again.
We are wondering whether it is worth having another procedure to improve quality of life when it is unclear that the approach and/or outcome will be different and the consequences of infection (though not common) can be severe. If he has the lead revision are there other procedures to help the lead stay in place?

[Michael J. McWilliams, M.D.]

I am sorry to hear that your husbands lead dislodged.  This happens about 1% of all cases.  The risk of infection reopening a pacemaker pocket is about 1:50.  

What I would advise my patient is to fix the lead.  I didn't think they would benefit from an extra lead, I shouldn't put it in to begin with.  Besides, the lead could move around and stimulate the diaphragm (breath muscle) or cause extra beats but irritating the heart muscle when it moves.

He might not need the atrial lead now, but he may need it in the future.  If you wait more than 6 months after implanting it, the lead starts to fibrose to the vessel wall and become more difficult to move, if not impossible, without the assistance of a laser sheath.  

Infections are not ideal, but if it gets infected early after implantation, it is relatively easy to remove.  After 6 months the risk of fibrosis to the vein walls increase and make it more complicated procedure.

I don't think there is any data to suggest that active fixation leads dislodge more or less than passive fixation leads.  What ever your doctor feels most comfortable with is the best answer.  Trust me that your doctor is equally unhappy about the lead dislodgement and is going to do everything in their power to make sure it doesn't happen again.

I hope this helps.

[dorain]

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[Joan724]

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[Moshe175]

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[silwin]

Thank you - that is very helpful. I think that my husband feels more comfortable proceeding with that information on hand.