Pacemaker

I  a 72 year old,  fit female. In January this year I had a PM fitted and I was discharged the same day not having an x ray which I had been told to anticipate a few days previous.  After 10 days the one lead was suddenly  stopped  working to full capacity. I was told the problem was either a faulty lead or the consultant had screwed in the lead too tightly. Another procedure was needed a few weeks later.The lead was tested and found to be o.k.   I was not told what the problem was, the consultant did not return to speak to me. I read in my notes the lead had been relocated. I had 2 x rays before being discharged. 

Should a routine x ray been taken after the first op? Would it have saved me a second painful procedure.

Thanks  in anticipation 

 


3 Comments

Post Pacemaker Implant X-Rays

by Marybird - 2021-04-20 15:05:28

Hi J10, 

It looks as though same day pacemaker surgery/discharge has become commonplace these days, and I thought at least one x-ray prior to discharge to check for lead positioning, as well as complications from the surgery was pretty much standard.

When I had my pacemaker implanted in June 2019, I was discharged about 8 hrs after the surgery- spent the post surgery time in the hospital telemetry unit, and had two chest x-rays before I was discharged, one about 2 hrs after the surgery and the second about 1 hr before I was discharged. This was, I was told, to check for lead placement and to make sure there were no complications from the surgery. All was ok.

If the lead in question was working for you until about 10 days after your implant, I'd guess that its placement, and its condition was intact right after your surgery, and an x-ray at that time might not have shown any problems. I don't know about leads being "screwed in too tight"- from what I have read about the "screw type" leads, there are specific instructions to putting those in to avoid damaging, or dislodging the leads, but I'm not sure what a problem such as this (?too tight?) would look like on an x-ray unless the lead became dislodged or something. 

Just from what you are saying, if the lead itself was ok, but stopped working 10 days or so after the implant ( but was working ok up to that point), it seems to me that perhaps it became dislodged, or something around that 10 day period. In that event it's not something that would have been seen on a chest x-ray done within hours after your pacemaker implant.

A similar thing happened to my sister, about two weeks or so after she got her pacemaker. Apparently one of her leads stopped working ( determined via her remote pacing report) and they determined the tip had become dislodged. She had it replaced, and apparently there was no discussion about how this might have happened. Might have been not placed well during the implant, or she might have been roughhousing with her then two year old twin grandsons ( my theory) and that pulled out the lead. She said she had had two x-rays before her discharge ( she stayed overnight) but these showed no problems.

 

Post lead implantation CXR

by crustyg - 2021-04-20 17:15:03

During lead implantation they use live-image X-rays to see where the leads are - fluoroscopy - and this is top-to-bottom, i.e. from the front of your chest to the back, as you would have been lying on your back.  Technically this is AP (antero-posterior).

A standard CXR is actually PA - back-towards-front (makes the heart outline slightly sharper as the heart is closer to the layer that actually creates the image - silver-halide film back in the day or an imaging screen now), but it's basically the same as the fluoroscopy view.  The real value of a post-procedure CXR isn't to document where the leads are in a PA-view (it's perfectly possible to grab a still from fluoroscopy), but to take a lateral view - side to side.  Which is not realistically possible on the operating table.  The value of a lateral CXR is to prove that the RV lead is NOT connected to/screwed into the anterior wall of the RV (quite thin) but is actually in the thick muscle between the RV and the LV.  Putting a lead into the RV-anterior wall with active fixation (the little metal screw that should hold it in place while fibrous tissue grows up around it and provides a really permanent anchor) can lead to perforation of the RV and this can quickly be fatal.  There's at least one contributor here who has had this happen to them - very lucky indeed.

The NHS now has lots of little money-saving policy savings and reducing 'unnecessary' medical imaging is one.  Many of these so-called 'unnecessary' imaging studies are actuallly essential, and the lack of them turn up in the staggering (and actuarially verfied) medical negligence liabilities of the NHS - which stood at £65BN in 2017.  And that was before the latest obstetric decade-of-concealed disaster was factored in.  No, I didn't mean £65M, I really did mean 65 BILLION pounds GBP.  That's about 50% of the total yearly spend on all aspects of the NHS in the UK.

Would that lateral-CXR have saved you from a lead-redo?  Almost certainly not. A lead that worked for 10days wouldn't have shown up on imaging.

A properly sized lead (i.e. the right length for your body), with active fixation, will hardly *ever* come loose in the first few weeks after implantation.  Active fixation isn't always appropriate or possible, however, and passively fixed leads are more likely to come loose.  Your hospital PM card *should* tell you exactly which leads you have implanted as well as your PM model and serial number.  This information tells you the sort of lead fixation in use.

Post lead correction.

by J10 - 2021-04-21 14:20:27

Thank you both for your comments and having taken the time to answer so fully. It is much appreciated. I now feel happier that the private hospital (that I paid a considerable sum to)was not cutting corners. If only the consultant had taken the time to speak to me before my discharge!

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