RV Lead Perforation

Has anyone been diagnosed wtih lead migration, lead perforation?  I'm having issues with RV pacing/performance with my BS Accolade L301 (put in 2018, which replaced my first PM, a St. Jude, which was put in 2011), which uses my original St. Jude leads from 2011.  Have always had issues with SOB with exercise and condition has worsened in past year (SOB with minimal exercise).  Current EP has reviewed my case, trying to adjust PM settings to improve performance during aerobic activities, but so far, hasn't helped.  He believes (but need imaging to comfirm) that my RV lead may have perforated chamber, causing less-than-optimum performance.  I just had long conversation with BS rep (at manufacturer) and says I should definitely ask that EP find out exactly where my lead is, and why lead repositioning hasn't been discussed.  But, after 8 years, that may not be an option at this point!  Any feedback would be greatly appreciated.


Imaging then respositioning.

by crustyg - 2019-11-04 13:45:15

Lead positioning - in a crude way - is very quickly established with a chest x-ray - PA and lateral, but a CT scan would be a lot better, if more costly.

Your PM should be able to provide a lot of data that might perhaps explain why pacing isn't delivering the cardiac output that you need - lead integrity, impedance, capture voltage+pulse width, all of which is collected during an interrogation of your box.

I *imagine* that your RV lead may not be where it should be: I'm told that one of the classic errors is placing the RV lead in the anterior wall (where it can easily perforate => death) instead of the RV septum to the LV, where perforation could be a real PITA as it might give you a L=>R shunt and could be difficult to fix.  An echo should show this.

Lead respositioning is always an option, no matter how long you've had the leads.  It's not trivial, but handled by a team that do scores or hundreds pa, it shouldn't be a big deal.  If your RV lead is actually pacing your LV then it should deliver what you need if the PM settings are appropriate for you (LRL/MSR and the pacing mode is correct).

Have you got the reports from your most recent interrogation?

RV Lead Perforation/Repositioning

by Aulee - 2019-11-04 20:38:08

Thanks, crustyg, for your helpful feedback!  Haven't got the reports from my last (10/22/19) interrogation but have a call in to pursue further.  Need more candid consult with EP & clearer understanding/confirmation (via imaging...) of his comment made at that last session.about possible perforation. 

RV Lead Perforation/Repositioning

by Aulee - 2019-11-05 10:26:54

More on this situation, and would appreciate any feedback/comments.  Just got EP's notes from last visit/interrogation.  Here's an exerpt which is what I had been told, except he didn't mention the part about "she may need to consider RV lead revision with something like a His bundle lead" so that was new to me.  Here's the exerpt:

"Today, I will have increased her max tracking rate 140 bpm.  I informed her that this may increase the amount of RV pacing, but balancing these 2 issues she would be happier with more exertional capacity even if this resulted in higher RV pacing burden.
  I have some concern about the ventricular lead.  It does appear quite apical.  The capture threshold is high.  She reports twitching.  It is possible that this has migrated and is partially perforated without causing leakage of blood.  In the future, if she paces more in the ventricle she may need to consider RV lead revision with something like a His bundle lead.  Looking at the CT scan the RV lead is clearly at the distal apex.  Bloom artifact limits a definitive evaluation of the lead location."


Ah, makes more sense.

by crustyg - 2019-11-05 12:20:18

Your EP doc's concern about RV pacing burden suggests that there's some concern about the heart muscle health + LV dysfunction from remodelling.  There's plenty of evidence now that prolonged RV pacing - in some patients - affects the operation of the LV and reduces the heart muscle's pumping efficiency, often measured with an echocardiogram as LV percentage Ejection Fraction (%LVEF, or %EF for short).  Simply driving the heart rate by allowing the PM to deliver a faster HR doesn't always increase cadiac output (which is what most of us need, and which is mostly delivered by increasing heart rate - via the PM).

If there's concern that the RV lead is not well placed (capture threshold is high) and the commonly seen 'spray of light' (the bloom) on the CT scan is obscuring the exact location of the tip of the lead then lead revision makes sense. Your EP is 'offering' a His-bundle replacement which delivers a much more natural pacing to the LV and RV and may well improve cardiac output and improve %EF.  This is effectively cardiac resynchronisation therapy without the risks of a third lead.

However, your RV lead extraction might be very difficult: it sounds as though your EP doc is a keeper!  There will be some *very* careful prep before this procedure in your case.

If it were me, I'd be pushing for the lead revision sooner rather than later: you will be having a long conversation about the risks and benefits.  You will want to be sure that the lead extraction team do a *lot* of these, and that they are ready to handle the complications.

Best wishes.

Lead Revision...

by Aulee - 2019-11-05 19:51:44

You obviously have a way better grasp on all of this than I do, crustyg, and I greatly appreciate your helping me understand what I may be dealing with here so I can have better conversations with my EP.  How do you know all of this?  Feel I need a course or two on cardiology/PMs especially now as we seem to be getting closer to a clearer diagnosis.  Do you by chance have any good references that might help with that, short of applying for medical school?!  I'm overwhelmed with trying to understand the long-term consequences re: my current situation and also the possible treatment options should we go in that direction.  I'm only 68 years old, have always been very active, but have been on a downward spiral (as far as any aerobic activity goes) ever since my first PM in 2011. 

RV pacing

by Pacedmyruns - 2019-11-19 04:07:04

I can tell you from my experience my doc thinks mine should be revised bc I can feel pacing. I pace 100% in the RV lead with exercise and I can tell you it takes time to get use to. I'm very active. I run at 12-15 miles a week and after many adjustments and many awful symptoms of pacing, we finally found the right setting. Doctors aren't use to active people and aren't the best at determining what we need beyond the basic

exercise adjustments. But I will say try more adjustments and try and find someone tolerable. It's not going to be perfect and you will have to learn to be a paced exerciser   I have learned not many RV pace with exercise! Most are A paced and it's not as hard on the heart as RV PACING. After I realized this, I realized why I struggled so much to run. It's a lot better now and the first 3-4 mins of exercise is hard but gets better as I continue. I have exercise induced block and my trade off is unnecessary pacing so I can exercise. Sucks but it's been good. So try setting changes first before revision. Make sure you won't have the same problem after revision that could have been fixed without a revision. 

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You have rhythm.

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