{
  "abstract": "Summary An 88-year-old female, afflicted by advanced frailty and multiple comorbidities, presented with respiratory symptoms to her general practitioner. Following a chest X-ray that revealed a fractured right atrial lead of her pacemaker, subsequent CT imaging confirmed the dislodgment of the fractured lead into the coronary sinus. Given her extensive comorbidities, a decision was made against intervention, opting to retain the fractured lead. This management plan was formulated after consultation with the cardiothoracic team, considering the patient's delicate health status and the potential risks associated with invasive intervention in her complex medical condition.Introduction Trauma-induced lead fractures continue to be a notable concern in the realm of pacemaker implantation, despite their rarity. Encountering a fractured lead without a preceding history of trauma is even more infrequent. For patients undergoing pacemaker insertion for known diseases, complications, or preventative measures, this complication can lead to severe and potentially lethal consequences. Existing literature offers limited documentation of traumatic fractures and minimal evidence of spontaneous, atraumatic fractures. This case report sheds light on a specific instance involving a non-traumatic pacemaker lead fracture, contributing to the comprehension of this seldom-reported phenomenon.Background This case report is presented due to the infrequent occurrence of pacemaker lead fractures in medical practice. Furthermore, subsequent dislodgement following such fractures is even rarer. Typically, the treatment approach for a fractured lead involves removal and replacement of either the lead or the entire pacemaker; however, conservative strategies, as seen in the current case, are infrequently employed. The decision to pursue additional interventions necessitates a careful consideration of potential benefits against associated risks. In this presented case, the proposed management plan was deemed to carry an elevated risk, rendering surgical intervention or exploration inappropriate within the context of this complex clinical scenario. The report underscores the significance of adopting a nuanced approach to such cases, emphasizing that interventions should be informed by a comprehensive evaluation of the individual patient's health status and potential risks. It recognizes that surgical solutions may not universally apply in intricate situations.Case presentation This case involves an 88-year-old female with a medical history notable for atrial fibrillation, ischemic heart disease, a permanent pacemaker, including a dual chamber device and an additional older right atrial lead observed on initial chest X-rays, type 2 diabetes mellitus, recurrent falls, haemochromatosis, and a documented Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) status from prior admissions.The initial pacemaker implantation predates 2007 and was performed at a different hospital, as Stepping Hill Hospital did not conduct Permanent Pacemaker Implantations (PPPMs) during that period. In 2012, a new right atrial lead was implanted at Stepping Hill Hospital, positioned more medially to the spine compared to the pre-existing right atrial lead.Chest X-ray from July 2020 showing the presence of two atrial leads, one of them was implanted before 2007, and the other was inserted in 2012 in Stepping Hill Hospital.Abstract 4-004 Figure 1In December 2020, the patient underwent a procedure involving the insertion of a new Right Ventricular lead due to an escalation in RV threshold. Concurrently, a transition was made to a single-chamber device tailored to manage atrial fibrillation (AF).Abstract 4-004 Figure 2In December 2022, the patient was admitted with chief complaints of chest pain, subsequently diagnosed with Non-ST Elevation Myocardial Infarction (NSTEMI), and managed through medical interventions. Her chest x-ray then was the one showed below:Abstract 4-004 Figure 3The fourth chest X-ray (CXR), conducted in July 2023, was initiated in response to respiratory symptoms as prompted by the patient's General Practitioner (GP). Subsequently, the GP sought cardiology advice and guidance via the electronic Referral Service (eRS) regarding the CXR findings. Notably, the report revealed the presence of a fractured tip of the right lead. It is important to highlight that the same abnormality was evident in a CXR conducted in March 2023, although it was not commented upon at that particular instance.Abstract 4-004 Figure 4Abstract 4-004 Figure 5The case involves a rare incident wherein the screw tip of one of the redundant right atrial leads underwent complete fracture, followed by an uncommon occurrence of dislodgment, a stage atypical for such events, as conventional expectations would entail the segment remaining affixed to the right atrium (RA). Determination of the precise embolized location of the lead tip is challenging through a standard chest X-ray (CXR).Identification of the redundant RA lead is facilitated by the distinct visualization of the tips of the two right ventricular (RV) leads, with the older lead exhibiting what appears to be a passive fix tip. The tip of one RA lead (medial, implanted at Stepping Hill Hospital in 2012) is discernible, while the tip of the more lateral RA lead (implanted considerably earlier at a different institution) remains elusive. Initial observations might suggest catching the tip ‘end on,’ but a closer examination refutes this assumption in the current context.In response to the aforementioned circumstances, the following measures were enacted:CT Scan for Positional Documentation:A CT scan was executed to meticulously document the precise position of the fractured lead.Consultation:Deliberation was given to engaging with cardiothoracic specialists or device/extraction experts, contingent on the CT findings.In the instance of this elderly lady, characterized by advanced age and significant co-morbidities, along with an existing DNACPR directive, any pursuit of intervention for lead removal was deemed excessively invasive, indisputably associated with a prohibitively high risk, and anticipated to yield minimal or no discernible benefits. Notably, the complication exhibited no correlation with preceding symptoms (Chest Pain in Dec 2022 or respiratory symptoms in July 2023). Despite the questionable utility of a CT scan without intervention, it was undertaken in her case to eliminate any association with respiratory symptoms. Moreover, the CT scan served as a judicious diagnostic tool to rule out other respiratory diseases as potential contributors to her current symptoms. The fractured lead, identified as a redundant RA lead, exerts no impact on the pacemaker's functionality. While an argument for anticoagulation in this context could be made, it is crucial to acknowledge that she is already undergoing anticoagulation therapy for atrial fibrillation (AF).The CT images below confirm the lead tip to be located in the coronary sinus. As previously indicated, the best course of action is to refrain from intervention. No causative factors for the respiratory symptoms were identified, and it is deemed appropriate to maintain the current management plan, leaving communication and coordination between the GP and the pacing clinic.Abstract 4-004 Figure 6Abstract 4-004 Figure 7Abstract 4-004 Figure 8It is noteworthy that this lady underwent a CT aorta in December 2022. Upon meticulous examination, the lead fracture can be discerned in those images as well.Abstract 4-004 Figure 9Discussion What sets apart this case from prior reports is the prolonged duration during which the patient harbored a dislodged and embolized fractured lead tip before seeking medical attention. Notably, this case was managed in a comparatively conservative manner, evident in the March x-ray that disclosed the presence of the fracture; however, symptomatic presentation only occurred in July 2023. It is noteworthy that all previously documented patients underwent prompt treatment within days following lead fracture.Moreover, the extraction of the fractured lead tip posed a formidable challenge with the potential for various complications, such as coronary sinus rupture, cardiac perforation, tamponade, or fatal outcomes. The chest CT scan in this instance revealed that the dislodged end of the fractured lead had embolized and was securely situated in the coronary sinus. Given the precarious nature of attempting removal, which could entail severe complications, including the risk of coronary sinus rupture, a decision was made against undertaking any extraction procedures.",
  "authors": [
    {
      "affiliations": [
        "Stockport NHS Foundation Trust, Stockport, UK"
      ],
      "name": "Ala Ahmad Mohammad Al-Qudah"
    },
    {
      "affiliations": [
        "Stockport NHS Foundation Trust, Stockport, UK"
      ],
      "name": "Amjad Khanfar"
    },
    {
      "affiliations": [
        "Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK"
      ],
      "name": "Esraa Damra"
    },
    {
      "affiliations": [
        "Stockport NHS Foundation Trust, Stockport, UK"
      ],
      "name": "Fahmida Mannan"
    },
    {
      "affiliations": [
        "Manchester University NHS Foundation Trust, Manchester, UK"
      ],
      "name": "Nadim Malik"
    }
  ],
  "title": "4-004 Coronary sinus dislodgement of pacemaker RA lead tip: a case report",
  "uid": "81cf4e01-6b3e-5fc2-b28a-1b3910637a41"
}