Correspondence

Malposition of a Pacemaker Lead

N Engl J Med 2002; 346:2010June 20, 2002

Article

To the Editor:

Firschke and Zrenner (Feb. 7 issue)1 describe a case of inadvertent malposition of a right ventricular pacing lead in the left ventricle. The patient was taking aspirin for coronary artery disease. Surprisingly, the authors state, “No action was taken, since there had been no complications during the previous four years and the pacemaker and lead functions were normal.” Patients with left ventricular leads are at significant risk for systemic embolization from thrombus formation on the lead, even when they are receiving antiplatelet therapy.2 Therefore, if timely removal of a malpositioned lead in the left ventricle is not performed, lifelong anticoagulation therapy with warfarin should be instituted.

Afshin Farzaneh-Far, M.R.C.P., Ph.D.
University College London Hospitals, London WC1E 6DB, United Kingdom
aff25@hotmail.com

2 References

1. 1

   Firschke C, Zrenner B. Malposition of dual-chamber pacemaker lead. N Engl J Med 2002;346:e2-e2
   Full Text | Web of Science | Medline

2. 2

   Van Gelder BM, Bracke FA, Oto A, et al. Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: a multicenter experience and review of the literature. Pacing Clin Electrophysiol 2000;23:877-883
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors and a colleague reply:

To the Editor: Dr. Farzaneh-Far refers to the summary of 28 case reports involving patients with a pacemaker lead inadvertently placed in the left ventricle.1 Eleven of the 28 patients had cerebral ischemia, in most cases two years or less after implantation of the lead. Cerebral ischemia occurred in 3 of 6 patients who were receiving antiplatelet medication, in none of 2 who were receiving warfarin, in 6 of 16 who were not receiving medication, and in 1 of 4 who were receiving unknown medication (P=0.36). Of four patients with cerebral ischemia, subsequently treated with warfarin, one had a recurrence of cerebral ischemia. The period of follow-up and the prevalence of concomitant risk factors, such as atrial fibrillation and valvular or vascular disease, were not reported. On the basis of these data, no conclusions can be drawn with regard to either the risk of thromboembolism associated with a left ventricular lead or a general therapeutic strategy for this condition.

In our patient, who was asymptomatic during a period of four years after implantation of the pacemaker, without evidence of thrombus on echocardiography and with no additional risk factors for cardiogenic thromboembolism, the risk of thromboembolism with continued use of aspirin was considered too low to justify surgical removal of the lead or initiation of oral anticoagulant therapy. In addition, the risk of bleeding complications associated with anticoagulation in a 78-year-old person with arterial hypertension has to be taken into consideration.2 Longer follow-up of the patients in the study described above1 may help to determine the most appropriate therapy for patients with a pacemaker lead inadvertently placed in the left ventricle.

Christian Firschke, M.D.
Bernhard Zrenner, M.D.
Adnan Kastrati, M.D.
Deutsches Herzzentrum München, D-80636 Munich, Germany
cfirschke@t-online.de

2 References

1. 1

   Van Gelder BM, Bracke FA, Oto A, et al. Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: a multicenter experience and review of the literature. Pacing Clin Electrophysiol 2000;23:877-883
   CrossRef | Web of Science | Medline

2. 2

   Palareti G, Leali N, Coccheri S, et al. Bleeding complications of oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT). Lancet 1996;348:423-428
   CrossRef | Web of Science | Medline