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Electrical Nightmare: a Case ofElectrical Nightmare: a Case of
Complete Heart Block, DilatedComplete Heart Block, Dilated
...
58 y/o man first seen in June 2004 for
consideration for biventricular pacing in
CHF NYHA III. On good medical Tx
Heart fa...
What would you do?What would you do?
A. Schedule for CRT-D
B. Schedule for CRT-P
C. Schedule for ICD
D. Order a new echoca...
Initial upgradeInitial upgrade
July 2004.
Moderate stenosis of left subclavian vein
Difficult CS cannulation
Lateral vein ...
What would you do?What would you do?
A. Place ICD lead in apex, dual-chamber
ICD
B. Place ICD lead in apex, place CRT-D
de...
Bifocal RV pacingBifocal RV pacing
We then placed a Gore-coated
defibrillation lead in the mid RV
septum.
We connected the...
Subsequent courseSubsequent course
Clinical improvement, creatinine 3.6
Oct 04 plan to construct AV fistula.
Insurance pro...
InfectionInfection
In June 05 he presents with fever, redness
around the dialysis catheter in right subclavian
vein.
Methi...
What would you do?What would you do?
A. Continue ATB
B. Remove system in left side, place new
system from right side in sa...
What type of temporary wire?What type of temporary wire?
A. Standard temporary ventricular pacing
wire
B. Active-fixation ...
ICD extractionICD extraction
June 29, 2005
Temporary wire from left femoral vein
Pocket clean
ICD lead removed with lockin...
Temporary pacemakerTemporary pacemaker
Right infraclavicular pocket
Axillary vein, active-fixation leads to RA
appendage a...
Subsequent courseSubsequent course
Discharged in 3 days, to complete 4
weeks of ATB
Blood cultures became negative
Lead cu...
More complicationsMore complications
In early July construction of right arm AV
fistula
Tunneled dialysis catheter in left...
Infection November 05Infection November 05
Redness and discharge around the
exit site of the extenders in the right
chest
...
What would you do?What would you do?
A. Treat medically
B. Request moving of dialysis catheter,
then implant ICD or CRT-D ...
New Pacemaker November 05 (138New Pacemaker November 05 (138
days of temporary pacing)days of temporary pacing)
Temporary ...
Subsequent courseSubsequent course
1 dose of vancomycin
Culture from extender yeast, coagulase-
negative Staphylococcus
Su...
What would you do?What would you do?
A. Complete new CRT-D from left side
B. Upgrade to CRT-D from right side
C. Upgrade t...
Upgrade to CRT-P August 06Upgrade to CRT-P August 06
Difficult left axillary vein access
Coronary sinus cannulated
Larger ...
10 month follow-up10 month follow-up
NYHA I
No readmissions
Dialysis 3 days a week
Nightmare case
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Nightmare case

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Nightmare case

  1. 1. Electrical Nightmare: a Case ofElectrical Nightmare: a Case of Complete Heart Block, DilatedComplete Heart Block, Dilated Cardiomyopathy, Infections,Cardiomyopathy, Infections, Difficult Venous AccessDifficult Venous Access Sergio L. Pinski, MD Cleveland Clinic Florida, Weston, FL
  2. 2. 58 y/o man first seen in June 2004 for consideration for biventricular pacing in CHF NYHA III. On good medical Tx Heart failure symptoms for a year In Feb 2004 dual-chamber PM for complete heart block in Indiana No-obstructive coronary artery disease, LVEF 25%, moderate mitral regurgitation Diabetes, retinopathy, nephropathy, proteinuria, creatinine of 4.2, peripheral vascular disease MDT 4574 in atrium, MDT 4092 in RV apex. Good thresholds, no escape.
  3. 3. What would you do?What would you do? A. Schedule for CRT-D B. Schedule for CRT-P C. Schedule for ICD D. Order a new echocardiogram to evaluate LV dyssynchrony E. Order left upper extremity venogram F. Something else G. Nothing, all futile with severe renal failure
  4. 4. Initial upgradeInitial upgrade July 2004. Moderate stenosis of left subclavian vein Difficult CS cannulation Lateral vein with very acute take-off and 2 bends. Cannulated with wire, but lead would not progress We also tried a small anterolateral vein, Easytrak I lead did not progress even after cutting tines.
  5. 5. What would you do?What would you do? A. Place ICD lead in apex, dual-chamber ICD B. Place ICD lead in apex, place CRT-D device, plug LV port, reattempt transvenous approach C. Place ICD lead in apex, place CRT-D device, plug LV port, refer for epicardial lead placement D. None of the above
  6. 6. Bifocal RV pacingBifocal RV pacing We then placed a Gore-coated defibrillation lead in the mid RV septum. We connected the old apical pacing lead to the RV port and the defibrillation lead to the LV port, to achieve bifocal RV pacing. Appropriate function.
  7. 7. Subsequent courseSubsequent course Clinical improvement, creatinine 3.6 Oct 04 plan to construct AV fistula. Insurance problems. Lost to F/U. Presents in Feb 05 with uremia, hyperkalemia, volume overload Started on dialysis through a right subclavian catheter He improves In March and April 05, referred again for vascular access, but misses appointment
  8. 8. InfectionInfection In June 05 he presents with fever, redness around the dialysis catheter in right subclavian vein. Methicillin-sensitive Staph aureus bacteremia Catheter moved first right femoral, then left IJ vein Vancomycin plus levofloxacin, then oxacillin plus gentamicin plus rifampicin Persistent fever, positive blood cultures for 7 days. TEE (suboptimal) no vegetations Leukocyte indium scan with no cardiac uptake ID recommends ICD extraction
  9. 9. What would you do?What would you do? A. Continue ATB B. Remove system in left side, place new system from right side in same session C. Remove system in left side, temporary wire until blood cultures persistently negative, then new system from right side D. Remove system, implant epicardial system in the same setting E. Remove system, try to elicit stable escape rhythm with isoproterenol F. None of the above
  10. 10. What type of temporary wire?What type of temporary wire? A. Standard temporary ventricular pacing wire B. Active-fixation temporary ventricular pacing wire C. Active-fixation permanent ventricular pacing wire D. Some type of dual-chamber temporary pacing E. Other
  11. 11. ICD extractionICD extraction June 29, 2005 Temporary wire from left femoral vein Pocket clean ICD lead removed with locking stylet and strong sutures RV apical lead released with locking stylet and strong sutures, but became entrapped in innominate vein, released with Laser sheath RA lead with heavy adhesions, required lasing all the way down to the RA
  12. 12. Temporary pacemakerTemporary pacemaker Right infraclavicular pocket Axillary vein, active-fixation leads to RA appendage and RV septum Leads connected to two extenders, tunneled and exteriorized below the right nipple, secured with sleeves, attached to an external permanent pacemaker Distal loops of leads, proximal loop of extender encased in a Dacron pouch
  13. 13. Subsequent courseSubsequent course Discharged in 3 days, to complete 4 weeks of ATB Blood cultures became negative Lead culture negative
  14. 14. More complicationsMore complications In early July construction of right arm AV fistula Tunneled dialysis catheter in left subclavian vein July, 29 2005 falls and suffers left hip Fx Left intertrochanteric open reduction and internal fixation Sent to rehab facility, back to us because of unfamiliarity with externalized pacemaker In Sep 2005, right AV fistula not mature, dialysis via left subclavian catheter
  15. 15. Infection November 05Infection November 05 Redness and discharge around the exit site of the extenders in the right chest No fever. No leukocytosis. Blood cultures negative. AV fistula still not working well, low flow. Dialysis via Quinton catheter in left subclavian vein
  16. 16. What would you do?What would you do? A. Treat medically B. Request moving of dialysis catheter, then implant ICD or CRT-D from left side. C. Remove current leads, place new leads from right side D. Try to salvage present leads, implant pacemaker on right side E. Send for epicardial system (PM, ICD, CRT-P, CRT-D) F. None of the above
  17. 17. New Pacemaker November 05 (138New Pacemaker November 05 (138 days of temporary pacing)days of temporary pacing) Temporary pacer from right femoral vein Pocket entered, dacron pouch partially fibrosed. No signs of infection. Extenders dissected free, cut and pulled from below. Atrial lead with good function Ventricular lead had good function, but with a circumferential breach in the insulation Access right axillary vein New lead to RV outflow tract Failed lead pulled out with simple traction New dual-chamber PM in right infraclavicular pocket Subcostal area debrided. Left open sinus to heal by secondary intention
  18. 18. Subsequent courseSubsequent course 1 dose of vancomycin Culture from extender yeast, coagulase- negative Staphylococcus Subcostal sinus healed with local treatment By December 2005, dialysis via AV fistula Tunneled catheter removed in January 2006 He develops progressive heart failure, despite aggressive dialysis in July 2006
  19. 19. What would you do?What would you do? A. Complete new CRT-D from left side B. Upgrade to CRT-D from right side C. Upgrade to CRT-P from right side D. Try to add LV lead from left side, then tunnel to right pocket for CRT-P E. Continue medical treatment, ultrafiltration
  20. 20. Upgrade to CRT-P August 06Upgrade to CRT-P August 06 Difficult left axillary vein access Coronary sinus cannulated Larger lead (Easytrak 3) delivered to posterolateral vein- Good thresholds Lead tunneled to right pocket Small pneumothorax, chest tube for 48 hours Immediate improvement in heart failure symptoms
  21. 21. 10 month follow-up10 month follow-up NYHA I No readmissions Dialysis 3 days a week

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