Author + information
- aPhiladelphia College of Osteopathic Medicine Georgia, Suwanee, Georgia
- bInternal Medicine Residency Program, Northside Hospital Gwinnett, Lawrenceville, Georgia
- cMedical College of Georgia, Augusta University, Augusta, Georgia
- dCardiovascular Group P.C., Lawrenceville, Georgia
- ↵∗Address for correspondence:
Ms. Jennifer D. Hua, Cardiovascular Group, 755 Walther Road, Lawrenceville, Georgia 30046.
Temporary epicardial pacing, routinely used after cardiac surgery, employs wires anchored to the epicardium allowing removal via traction. In cases of resistance, the temporary wires are cut flush at the skin. We present a rare noninfectious case of a migrated retained temporary pacing wire into the left heart. (Level of Difficulty: Beginner.)
- cardiac pacemaker
- temporary cardiac pacing
- temporary epicardial pacemaker
- x-ray fluoroscopy
An asymptomatic 65-year-old man, with a history of minimally invasive aortic valve replacement 2 years prior, presented for an outpatient transesophageal echocardiogram (TEE). The TEE revealed a linear density beginning in the left ventricle (LV) adjacent to the anterior leaflet of the mitral valve (Figure 1A) before crossing through the bioprosthetic aortic valve and finally terminating in the ascending aorta proximal to the brachiocephalic artery. Computed tomography angiography confirmed a thin linear metallic foreign body measuring up to 15 cm (Figure 1B). On subsequent fluoroscopy, the object appeared to be fixed in the LV, free-floating at the level of the aortic valve as well as within the ascending aorta (Figure 1C).
Employing the aforementioned noninvasive imaging modalities, we formulated a plan to retrieve the foreign body. The TEE first revealed the linear density, and computed tomography angiography ruled out aortic dissection and offered further insight into its position. Additionally, use of fluoroscopy allowed us to evaluate its movement and determined the distal end was unattached. Interventional radiology was consulted to attempt percutaneous snare removal of the object with cardiac surgery on standby. Successful retrieval of the foreign body revealed a migrated temporary epicardial pacing wire (Figure 1D). After tolerating the procedure, the patient had stable mitral valve function and was subsequently discharged.
During the aortic valve replacement procedure 2 years prior, bipolar pacing wires were placed on the ventricle while 2 atrial wires were attached to the atrial epicardium and tunneled through the skin. Temporary epicardial pacing, routinely used after cardiac surgery, employs wires lightly anchored to the epicardium which allows for removal via gentle traction through the skin. In cases of resistance, the temporary wires are cut flush at the skin (1). The migration of retained temporary epicardial pacing wires is very rare but has been suspected to be due to direct perforation of the cardiac musculature or neighboring vascular structures. Most reported cases occurred within the context of an infection—a possible source of tissue weakening and disruption leading to direct perforation (2).
The mechanism of this wire’s migration from its original attachment at the epicardium of the right atrium into the LV is still anatomically unclear, as it was found entirely within the left heart and aorta under noninfectious conditions. It was fortuitously affixed to a chord of the mitral valve apparatus, preventing further travel into the aorta. Among previously reported cases, the few wires that had migrated into the left heart were all found within the aorta or carotid arteries—none had been found within the LV. Only 1 other case (2) describes left-sided migration under noninfectious conditions. Previous cases hypothesized that the wires may have perforated through the aortic wall (3). In our patient, the chance event of the wire fortuitously attaching to the mitral valve apparatus and its predominantly LV location rule out aortic perforation. The treatment options are percutaneous endovascular retrieval or surgical repair, with endovascular intervention being the preferred, less invasive option (3).
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reports author instructions page.
- Abbreviations and Acronyms
- left ventricle/ventricular
- transesophageal echocardiogram
- Received February 12, 2020.
- Revision received April 19, 2020.
- Accepted April 28, 2020.
- 2020 The Authors