Puncturing a lung to add a new lead

My 9 year old Medtronic 2 lead pacemaker is coming up to needing to be replaced due to the battery reaching end of life. I am 100% dependent following a surgical complication when my aortic valve was replaced at that time.

The doctor at Barts hospital said that they are considering changing the type of device to a three lead version, as this is more suitable for someone being paced long term (I am now 56yo), and can also help with heart failure. However, he said it comes with some risks, mostly due to the fact that they have to puncture a lung to route the new lead into the heart.

Does anyone have any thoughts as to the risk level? I will be guided by the doctors of course, and do want to have it 'upgraded', so am doing some research into it.

(I am on Warfarin as it is a mechanical valve, but that is not a primary concern as I am sure they will deal with that).

Many thanks!


9 Comments

Puncture a lung?

by AgentX86 - 2022-09-04 10:59:40

I've never heard of them having to puncture a lung to route a lead.

Are you certain that he didn't say that puncturing a lung was one of the risks of placing a lead?  That risk is there for any lead placement surgery.  It has littke to do with the third lead. This risk of this is non-zero but you've already taken that risk twice. I certainly would let it stop me.

Whether or not the third lead will help, only your doctors would know your details but even they don't know. If they're suggesting it, I'd do it.  You're hiring them for their expertise. Unless the risk is high and likely life-threatening, I take it.  They're covering their butt by telling you the risks - "informed consent".  If you're worried, ask exactly what the risk is.  Generally and with *your* surgeon. I think  you'll find that it's a small number.  If it's 1%, well, it can't be 0%.

Complications from an upgrade?

by Gemita - 2022-09-04 11:50:54

Andy I understand your concerns since that third lead to the left ventricle can prove “tricky” to place in some patients.  I am assuming your other two leads are still good and will remain in place, so it will be one new lead and a slighter bigger device which hopefully will still fit into your current pocket?  

There is always a very small risk of damage to the heart or lungs requiring surgery, including puncturing the heart or lungs, but they have to tell you about this as well as other serious and non serious risks.  Other complications I was told could include lead dislodgement or the third lead causing diaphragmatic stimulation, but in experienced hands an upgrade of your current system should not result in a significant complication.  I attach a link listing the potential risks of CRT surgery, although clearly you have already got your two leads in place.

I am sure your consultant under Bart’s is experienced and would not be recommending an upgrade without a real need.  Have you asked whether he has seen signs of heart failure or other physical signs of dyssynchrony or cardiomyopathy from RV pacing to cause concern, or is he wishing to upgrade for prevention alone?  We often discuss RV pacing and I believe most of us understand the potential long term risks from RV pacing although of course not all will experience detrimental effects.

In your shoes I would want to know what evidence has been found for the recommendation for a CRT system?  If clear evidence has been found, and I suspect it has, I would not hesitate to accept an upgrade.  If no evidence has been seen of any difficulties with RV pacing, I would perhaps consider a straightforward battery change alone when it is due and re-visit the CRT decision at the next battery change or sooner if needed, when technology has advanced and other placement areas for that left ventricular lead have been better perfected?  Anyway, please copy and paste the following helpful link(s) into your main browser.  I am certain, if needed, the benefits of CRT will outweigh the risks of the procedure.  The second link details the challenges of placing the LV lead:-

https://www.wsh.nhs.uk/CMS-Documents/Patient-leaflets/CardiacCare/6422-1-Pacemaker-pre-admission-information-for-patients-V2.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7244170/

Thank you!

by LondonAndy - 2022-09-04 16:12:13

Thank you AgentX86 and Gemita - especially for the links. I agree: I will go with the professionals's recommendation but it is useful to be an informed patient. 

At the time of my conversation with the Barts doctor he did not have the benefit of the most recent echocardiogram, and is obtaining it from my local hospital. The operation is not expected until December, so they will have a better view by then.

Punctured lung?

by Aberdeen - 2022-09-04 23:02:49

I had a dual lead pacemaker replaced by a CRT pacemaker. A punctured lung is definitely something that should not happen unless something untoward occurs. I think this is a rare complication that happens with any type of pacemaker operation.

 Good luck!

upgrading to CRT

by Tracey_E - 2022-09-06 11:55:57

Has your heart function dropped or is this preventative?

We are the same age, I've been paced since 1994. I had a doctor suggest upgrading mine as a preventative measure to prevent heart failure when I had my last replacement. My leads were working well so I said no thanks, when leads need replaced or my function drops, we can have the conversation again. My doctor was ok with that decision and didn't push upgrading.

I've since switched to an adult congenital ep, so he sees many patients paced long term. He said he would not want to give me a CRT, he's seen no evidence that it prevents anything so he does not agree with doing it as a preventative measure. He also said that if we've been paced 5 years without a drop in function, then he almost never sees it drop later and he does not consider me at risk of heart failure. 

They don't puncture a lung to run the third lead. I believe you may have misheard. 

Three leads

by Lavender - 2022-09-08 11:42:20

I already have a CRT-P (three leads). They don't want or try to puncture a lung to install it. Maybe he was mentioning a risk. Don't worry. You are not their first rodeo✌🏼

Three leads

by AgentX86 - 2022-09-08 14:10:09

I only have two (RV and LV, no RA) but, no, there is no puncuring the lung for the third lead. It's actually in the RA, fished around the back of the heart in the coronary sinus vein (which brings blood from the heart muscle itself, back to the right atrium for recirculation), behind the left ventricle.  It doesn't enter either ventricle and is more like the right atrial lead regarding where and how it's routed. It certainly doesn't enter the lung.

Thank you!

by LondonAndy - 2022-09-11 05:10:21

Thanks all for the useful comments. It seems likely that I misheard, or perhaps misunderstood something that was poorly expressed about the lung puncture, and in any event I will take their advice as to the best way forward. I had only expected a battery check on my last visit, and so the discussion about device change took me a bit by surprise and I would have made notes if I had known. But there will be another chance for me to discuss this with them before the op of course.

For those not in the UK, Barts is a centre of excellence for cardiac care, so I have no worries about their level of knowledge and skill. It is the oldest hospital in the UK, dating back to 1123, with very modern facilities including eight MRI units. 

Tracey_E: I have a degree of heart failure from before the operation on my aoritic valve in 2014, caused by the extended period of time (about as year) I had severe stenosis whilst going through a protracted series of diagnosis tests. The third lead was described as enabling more even pacing in the heart, avoiding the stimulation always being at the same point and being closer to natural pacing.

Punctured lung

by crustyg - 2022-09-13 11:15:14

If I understand your situation correctly you're facing placement of a third lead for CRT.  So they will have to insert a sheath into your subclavian vein to introduce this new lead, and it's the setup for placement of the (temporary) sheath that carries the risk.  There are two main approaches to a blind sheath insertion (i.e. NOT a surgical cut-down) and one has a higher risk of hitting the apex of the left lung.  In short, they advance a needle down towards the vein using anatomical landmarks and once in the vein run a guide wire through the hollow needle: remove needle, advance the sheath *over* the wire.  This is the technique described by Seldinger in 1953.  For this purpose it's not really possible/necessary to use ultrasonic guidance (but one would to sample blood in-utero).

Putting the sheath into the usual place runs the risk of damaging one of the existing pacing wires so they have to enter the vein a little away from the optimal position - and that's where the increased risk of hitting the lung comes from.  Pranging a pacing wire with the extremely sharp needle will result in greatly reduced PM battery life, OR force replacement of the lead(s).

Who'd be a doc?

I hope it goes well for you.

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