This image comes with courtesy of the Journal of SCAI Jai Parekh, Vikram Sharma, Jared Robl,et al Journal of the Society for Cardiovascular Angiography & Interventions 3 (2024) 101310
What is your diagnosis ?
I thought, it was pacemaker extrusion. It was indeed a close answer, still terribly wrong. It is an intentional exterior placement of a permanent pacemaker generator mimicking an extrusion due to pocket infection. Here is a patient, where a permanent pacemaker was kept temporarily for a few weeks or a month in high-risk reversible complete heart block situations. This typically occurs after an inferior posterior myocardial infarction, drug-induced CHB.
Currently, with the arrrival of TAVR, CHB has beceome a glamorous complication and is getting wider attention. This happens due to the anatomical uncertainties where the inferior landing zone of TAVI is pre-destained and is beyond our control. This is more true in the self expanding Core valve platform . When the lower edge treaspass the non-coronary cusp- membranous septal junction, it hits perfectly the compact post-penetrating bundle of His, confering a high risk of CHB.
Still, the good thing is some of them recover as the pressure edema regress .Putting a PPM in all such patients was considered mandatory or even a vanity in the past. Now we realise it is an additional metallic luggage in an already strained heart, Temporary-PPM the oxymoronic innovation is perfect option in this setting.
Final message
A typical external temporary pacemaker can be kept for up to 2 weeks maximum. (We have kept it for a month or so) It’s done via the jugular, subclavian, or even femoral. If the underlying condition demands more time for recovery of CHB, many do a regular permanent pacemaker.
Now , we have this unique option of using PPM as TPM. This is not a new concept though. It was used few decades ago .Has come back in more centers .Thanks to TAVI and its specific complications.
Reference
1.Rodés-Cabau J. Ellenbogen K.A. Krahn A.D. et al. Management of conduction disturbances associated with transcatheter aortic valve replacement: JACC Scientific Expert Panel. J Am Coll Cardiol. 2019; 74: 1086-1106.
2. Leong D, Sovari AA, Ehdaie A, Chakravarty T, Liu Q, Jilaihawi H, Makkar R, Wang X, Cingolani E, Shehata M. Permanent-temporary pacemakers in the management of patients with conduction abnormalities after transcatheter aortic valve replacement. J Interv Card Electrophysiol. 2018 Jun;52(1):111-116. doi: 10.1007/s10840-018-0345-z. Epub 2018 Mar 12. PMID: 29532275.
Dr.S.Venkatesan MD 