A client with an implantable cardioverter-defibrillator develops ventricular tachycardia

Journal Article

Joshua M. Cooper,

Cardiovascular Division, Department of Internal Medicine

,

University of Pennsylvania Health System

,

3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104

,

USA

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Published:

24 November 2010

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  Joshua M. Cooper, Nimrod Lavi, Glenn M. Polin, Sanjay Dixit, Ralph J. Verdino, Temporary external implantable cardioverter defibrillator in the pacemaker-dependent ventricular tachycardia patient, EP Europace, Volume 13, Issue 5, May 2011, Pages 761–763, //doi.org/10.1093/europace/euq412

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Abstract

Case

When an implanted pacemaker or implantable cardioverter defibrillator (ICD) becomes infected, the entire system, including the pulse generator and all leads, must be removed for infection resolution. The timing of permanent device re-implantation is dependent upon infection severity, the effectiveness of antimicrobial treatment, and the documentation of sterile blood cultures. In a pacemaker-dependent patient, temporary pacing is needed until the new device system can be implanted. An active fixation permanent pacemaker lead can be percutaneously implanted via the internal jugular or subclavian vein and attached to a resterilized, external permanent pacemaker for temporary right ventricular (RV) pacing.1 This technique is associated with fewer adverse events than other temporary pacing modalities and is cost-effective.2,3 In ICD patients with recurrent ventricular tachycardia (VT) after device extraction, tachyarrhythmias also need to be managed.

A 74-year-old man with ischaemic cardiomyopathy was transferred to our institution with a purulent pocket infection and severe sepsis with Staphylococcus aureus, 3 weeks after an ICD generator change. His dual-chamber ICD was implanted 9 years prior for VT, and he developed complete heart block in the interim, leaving him pacemaker-dependent. His left ventricular ejection fraction was 30%, and, since the recent ICD replacement, he had 81 episodes of asymptomatic monomorphic VT (cycle length 370–430 ms), despite chronic treatment with amiodarone. Each episode was successfully terminated with a single anti-tachycardia pacing (ATP) burst, and no shocks were delivered.

On presentation, he was ill-appearing, with persistent methicillin-sensitive S. aureus bacteraemia and fevers to 103°F, despite treatment with intravenous nafcillin. The patient underwent device removal, extensive debridement of the grossly purulent left pectoral device pocket, and laser extraction of his chronic atrial and ventricular leads. A femoral quadripolar catheter was used for temporary pacing during the procedure. The right internal jugular vein site was then sterilely prepped, an active fixation permanent pacemaker lead was percutaneously implanted in the RV apex, and the lead was connected to an external resterilized ICD generator (Figure 1). The ventricular pacing threshold was 0.4 V at 0.5 ms. The device was programmed for bradycardia pacing at VVI 80 p.p.m., and a VT zone of 140–250 b.p.m. was set, with six burst ATP therapies only.

Figure 1

(Top, left) Chest radiograph of temporary pacing system. An active fixation permanent pacemaker lead is affixed to the RV apex (black arrow) and is connected to an external ICD (black asterisk), which is secured to the neck with an adhesive dressing. (Top, right) Photograph of external temporary pacing system at the time of removal. The pacemaker lead is sutured to the skin via its suture sleeve at the right internal jugular vein access site (white arrow) and is connected to a resterilized ICD (white asterisk). (Bottom) Sample telemetry strip from a VT event after extraction of the infected ICD system. Ventricular tachycardia is successfully detected and treated by the temporary pacing/external ICD system with a single 10-pulse burst of ATP. VVI pacing at 80 p.p.m. is seen after VT termination, with heart block and dissociated P-waves noted.

The patient remained intubated after the extraction procedure because of S. aureus pneumonia, and a tracheostomy was necessary after 2 weeks because of ongoing dependence on mechanical ventilation. He required ongoing pressor support due to sepsis-induced hypotension in the setting of severe cardiomyopathy, and his critical clinical status precluded a VT ablation procedure. Over a 5-week period, the temporary device system provided reliable pacing and multiple successful ATP therapies for recurrent monomorphic VT, and no external shocks were needed. The patient recovered from his infection, and a new permanent right-sided biventricular ICD was implanted in the right pectoral region.

Conflict of interest: J.M.C., S.D., and R.J.V. have modest conflicts of interest to report with Medtronic, Boston Scientific, St Jude, and Biotronik in the form of modest honoraria for educational programmes and training support for the institution's fellowship programme.

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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email:

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email:

Topic:

• artificial cardiac pacemaker
• tachycardia
• sepsis
• tachycardia, ventricular
• heart block
• ventricular tachycardia, monomorphic
• pacemaker leads
• temporary cardiac pacemaker procedure
• implantable defibrillators
• ischemic cardiomyopathy
• infections
• medical devices
• generators

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