This patient had a long history of complete heart block, dilated cardiomyopathy, infections, and difficult venous access complicating his care. Over several years he underwent: 1) Biventricular pacemaker upgrade attempts through difficult veins. 2) Bifocal RV pacing using an apical and septal lead when coronary sinus cannulation failed. 3) Multiple device extractions and replacements due to infections, with the use of a temporary externalized pacing system for over 3 months. 4) An eventual successful upgrade to a CRT-P device through the left axillary vein with improvement in his heart failure.

1. Electrical Nightmare: a Case ofElectrical Nightmare: a Case of
Complete Heart Block, DilatedComplete Heart Block, Dilated
Cardiomyopathy, Infections,Cardiomyopathy, Infections,
Difficult Venous AccessDifficult Venous Access
Sergio L. Pinski, MD
Cleveland Clinic Florida, Weston, FL

2. 58 y/o man first seen in June 2004 for
consideration for biventricular pacing in
CHF NYHA III. On good medical Tx
Heart failure symptoms for a year
In Feb 2004 dual-chamber PM for
complete heart block in Indiana
No-obstructive coronary artery disease,
LVEF 25%, moderate mitral regurgitation
Diabetes, retinopathy, nephropathy,
proteinuria, creatinine of 4.2, peripheral
vascular disease
MDT 4574 in atrium, MDT 4092 in RV
apex. Good thresholds, no escape.

5. What would you do?What would you do?
A. Schedule for CRT-D
B. Schedule for CRT-P
C. Schedule for ICD
D. Order a new echocardiogram to
evaluate LV dyssynchrony
E. Order left upper extremity venogram
F. Something else
G. Nothing, all futile with severe renal
failure

6. Initial upgradeInitial upgrade
July 2004.
Moderate stenosis of left subclavian vein
Difficult CS cannulation
Lateral vein with very acute take-off and 2
bends.
Cannulated with wire, but lead would not
progress
We also tried a small anterolateral vein,
Easytrak I lead did not progress even
after cutting tines.

7. What would you do?What would you do?
A. Place ICD lead in apex, dual-chamber
ICD
B. Place ICD lead in apex, place CRT-D
device, plug LV port, reattempt
transvenous approach
C. Place ICD lead in apex, place CRT-D
device, plug LV port, refer for epicardial
lead placement
D. None of the above

8. Bifocal RV pacingBifocal RV pacing
We then placed a Gore-coated
defibrillation lead in the mid RV
septum.
We connected the old apical pacing
lead to the RV port and the
defibrillation lead to the LV port, to
achieve bifocal RV pacing.
Appropriate function.

11. Subsequent courseSubsequent course
Clinical improvement, creatinine 3.6
Oct 04 plan to construct AV fistula.
Insurance problems. Lost to F/U.
Presents in Feb 05 with uremia,
hyperkalemia, volume overload
Started on dialysis through a right
subclavian catheter
He improves
In March and April 05, referred again for
vascular access, but misses appointment

12. InfectionInfection
In June 05 he presents with fever, redness
around the dialysis catheter in right subclavian
vein.
Methicillin-sensitive Staph aureus bacteremia
Catheter moved first right femoral, then left IJ
vein
Vancomycin plus levofloxacin, then oxacillin
plus gentamicin plus rifampicin
Persistent fever, positive blood cultures for 7
days.
TEE (suboptimal) no vegetations
Leukocyte indium scan with no cardiac uptake
ID recommends ICD extraction

13. What would you do?What would you do?
A. Continue ATB
B. Remove system in left side, place new
system from right side in same session
C. Remove system in left side, temporary
wire until blood cultures persistently
negative, then new system from right
side
D. Remove system, implant epicardial
system in the same setting
E. Remove system, try to elicit stable
escape rhythm with isoproterenol
F. None of the above

14. What type of temporary wire?What type of temporary wire?
A. Standard temporary ventricular pacing
wire
B. Active-fixation temporary ventricular
pacing wire
C. Active-fixation permanent ventricular
pacing wire
D. Some type of dual-chamber temporary
pacing
E. Other

15. ICD extractionICD extraction
June 29, 2005
Temporary wire from left femoral vein
Pocket clean
ICD lead removed with locking stylet and
strong sutures
RV apical lead released with locking stylet
and strong sutures, but became entrapped in
innominate vein, released with Laser sheath
RA lead with heavy adhesions, required
lasing all the way down to the RA

18. Temporary pacemakerTemporary pacemaker
Right infraclavicular pocket
Axillary vein, active-fixation leads to RA
appendage and RV septum
Leads connected to two extenders,
tunneled and exteriorized below the right
nipple, secured with sleeves, attached to
an external permanent pacemaker
Distal loops of leads, proximal loop of
extender encased in a Dacron pouch

22. Subsequent courseSubsequent course
Discharged in 3 days, to complete 4
weeks of ATB
Blood cultures became negative
Lead culture negative

24. More complicationsMore complications
In early July construction of right arm AV
fistula
Tunneled dialysis catheter in left subclavian
vein
July, 29 2005 falls and suffers left hip Fx
Left intertrochanteric open reduction and
internal fixation
Sent to rehab facility, back to us because of
unfamiliarity with externalized pacemaker
In Sep 2005, right AV fistula not mature,
dialysis via left subclavian catheter

25. Infection November 05Infection November 05
Redness and discharge around the
exit site of the extenders in the right
chest
No fever. No leukocytosis. Blood
cultures negative.
AV fistula still not working well, low
flow. Dialysis via Quinton catheter in
left subclavian vein

29. What would you do?What would you do?
A. Treat medically
B. Request moving of dialysis catheter,
then implant ICD or CRT-D from left side.
C. Remove current leads, place new leads
from right side
D. Try to salvage present leads, implant
pacemaker on right side
E. Send for epicardial system (PM, ICD,
CRT-P, CRT-D)
F. None of the above

30. New Pacemaker November 05 (138New Pacemaker November 05 (138
days of temporary pacing)days of temporary pacing)
Temporary pacer from right femoral vein
Pocket entered, dacron pouch partially fibrosed. No
signs of infection.
Extenders dissected free, cut and pulled from below.
Atrial lead with good function
Ventricular lead had good function, but with a
circumferential breach in the insulation
Access right axillary vein
New lead to RV outflow tract
Failed lead pulled out with simple traction
New dual-chamber PM in right infraclavicular pocket
Subcostal area debrided. Left open sinus to heal by
secondary intention

34. Subsequent courseSubsequent course
1 dose of vancomycin
Culture from extender yeast, coagulase-
negative Staphylococcus
Subcostal sinus healed with local
treatment
By December 2005, dialysis via AV fistula
Tunneled catheter removed in January
2006
He develops progressive heart failure,
despite aggressive dialysis in July 2006

35. What would you do?What would you do?
A. Complete new CRT-D from left side
B. Upgrade to CRT-D from right side
C. Upgrade to CRT-P from right side
D. Try to add LV lead from left side, then
tunnel to right pocket for CRT-P
E. Continue medical treatment,
ultrafiltration

36. Upgrade to CRT-P August 06Upgrade to CRT-P August 06
Difficult left axillary vein access
Coronary sinus cannulated
Larger lead (Easytrak 3) delivered to
posterolateral vein- Good thresholds
Lead tunneled to right pocket
Small pneumothorax, chest tube for 48
hours
Immediate improvement in heart failure
symptoms

42. 10 month follow-up10 month follow-up
NYHA I
No readmissions
Dialysis 3 days a week