BACKGROUND: Pacemaker-induced right atrial thrombus is a rare condition that has not been described in the Emergency Medicine literature. This is a potentially fatal condition that is diagnosed with an echocardiogram and treated with surgical removal, thrombolytics, or long-term anticoagulation.
OBJECTIVES: This case report is designed to increase awareness among emergency physicians of this potentially fatal condition.
CASE REPORT: We describe the case of a patient with a massive right atrial thrombus secondary to pacemaker wire who presented to the Emergency Department with syncope, bradycardia, and rapid hemodynamic deterioration.
CONCLUSION: Emergency physicians should be aware of this life-threatening entity. Emergency bedside cardiac ultrasound or echocardiogram may be of value in its early identification

Feuchter, Alexander C

Katz, Kenneth D, MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Toxicology Division Right atrial thrombus secondary to pacemaker wires. Alexander C Feuchter Kenneth D. Katz MD Lehigh Valley Health Network, kenneth_d.katz@lvhn.org Follow this and additional works at: https://scholarlyworks.lvhn.org/toxicology  Part of the Medicine and Health Sciences Commons Published In/Presented At Feuchter AC, Katz KD. Right atrial thrombus secondary to pacemaker wires. J Emerg Med. 2012 Sep;43(3):e185-7. doi: 10.1016/j.jemermed.2010.04.047. Epub 2010 Jul 24. This Article is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. ClinicalCommunications: AdultsRIGHT ATRIAL THROMBUS SECONDARY TO PACEMAKER WIRESAlexander C. Feuchter, MD,* and Kenneth D. Katz, MD†*University of Pittsburgh Affiliated Residency in Emergency Medicine, and †Department of Emergency Medicine, Universityof Pittsburgh Medical Center, Pittsburgh, PennsylvaniaReprint Address: Alexander C. Feuchter, MD, Affiliated Residency in Emergency Medicine, University of Pittsburgh Medical Center,230 McKee Place, Suite 500, Pittsburgh, PA 15213, AbstractdBackground: Pacemaker-induced right atrialthrombus is a rare condition that has not been described inthe Emergency Medicine literature. This is a potentially fa-tal condition that is diagnosed with an echocardiogram andtreated with surgical removal, thrombolytics, or long-termanticoagulation. Objectives: This case report is designed toincrease awareness among emergency physicians of this po-tentially fatal condition. Case Report: We describe the caseof a patient with a massive right atrial thrombus secondaryto pacemaker wire who presented to the Emergency Depart-ment with syncope, bradycardia, and rapid hemodynamicdeterioration. Conclusion: Emergency physicians shouldbe aware of this life-threatening entity. Emergency bedsidecardiac ultrasound or echocardiogram may be of value inits early identification.  2012 Elsevier Inc., Keywordsdpacemaker; atrial thrombus; syncope;echocardiography; AICDINTRODUCTIONImplanted pacemakers are a common and safe treatmentfor bradydysrhythmias. However, serious thromboticand embolic complications of implanted cardiac pacingoccur in 0.6e3.5% of cases (1). Clinical presentations in-clude: asymptomatic findings on routine echocardiogram,dyspnea, embolic stroke, and unstable cardiac dysrhyth-mias (2e5). Because this clinical entity has not beendescribed in the emergency medicine literature, this casereport serves to make emergency physicians aware ofthe potentially life-threatening complications.CASE REPORTA 66-year-old man with hemodialysis-dependent end-stage renal disease, diabetes mellitus, severe ischemicheart disease with dual chambered pacemaker, andautomated implantable cardioverter-defibrillator (AICD)was transported to the Emergency Department (ED) byprivate vehicle after a syncopal episode earlier that even-ing. He reported walking to the kitchen when he suddenlylost consciousness. He was found within seconds by hiswife, regained consciousness immediately, and was trans-ported to the ED. The patient stated that he had been feel-ing generally unwell for the past 3 days without otheraccompanying complaints except for intermittent short-ness of breath. The AICD had not fired, and he had beendialyzed on schedule 2 days before presentation. Hismed-ications included: digoxin, calcium acetate, gabapentin,aspirin, carvedilol, Humulin R (Eli Lilly and Company,Indianapolis, IN), allopurinol, colchicine, and NEPHRO-CAPS (Fleming Pharmaceuticals, Fenton, MO).Initial vital signs included: paced heart rate of 44beats/min, blood pressure of 102/53 mm Hg, room airpulse oximetry 99%, temperature 36.8 C, and respira-tory rate 16 breaths/min. In general, he was alert andoriented and in no acute distress, with a Glasgow ComaScale score of 15. Physical examination revealed onlyRECEIVED: 10 October 2009; FINAL SUBMISSION RECEIVED: 19 January 2010;ACCEPTED: 11 April 2010e185The Journal of Emergency Medicine, Vol. 43, No. 3, pp. e185ee187, 2012Copyright  2012 Elsevier Inc.Printed in the USA. All rights reserved0736-4679/$ - see front matterdoi:10.1016/j.jemermed.2010.04.047Downloaded for Anonymous User (n/a) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on June 27, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.bradycardia and chronic bilateral pitting edema in thelower extremities. The patient was placed on a cardiacmonitor, nasal cannula oxygen was administered, pacingpads were placed, and intravenous access was obtained.At that time, no additional intervention was performeddue to the presence of stable bradycardia. An electrocar-diogram (ECG) revealed a paced rhythm at 50 beats/minwith unchanged ventricular morphology, compared withan ECG obtained 2 months prior. The QRS durationwas 192 ms, and the QTc was 481 ms. Laboratory diag-nostics were obtained and sent for analysis. However,before obtaining the results, the patient’s clinical condi-tion deteriorated rapidly within 30 min, with decreasedresponsiveness, severe dyspnea, and progressive brady-cardia that deteriorated rapidly to asystole. Despiteimmediate endotracheal intubation, external pacing,Advanced Cardiac Life Support protocol implementa-tion, and treatment of presumed hyperkalemia (avoidingcalcium because serum digoxin level was unavailable atthe time), the patient expired after a brief return ofspontaneous circulation.Laboratory studies, which were received after the timeof arrest, included: sodium129mEq/L (136e146), grosslyhemolyzed potassium 14 mEq/L (3.5e5) (repeat, alsohemolyzed, 8.9mEq/L), chloride 94mEq/L (95e110), bi-carbonate 17 mEq/L (21e31), blood urea nitrogen 77 mg/dL (5e20), creatinine 10.4 mg/dL (0.5e1.4), glucose81 mg/dL (70e99), and troponin I 0.24 ng/mL (< 0.1).Complete blood count was normal, and serum digoxinlevel was undetectable. A chest radiograph done just be-fore deterioration was unchanged from his previous studyobtained approximately 2 months earlier that demon-strated cardiac enlargement, evidence of sternotomy andcoronary artery bypass surgery, and a left subclaviandual-chamber pacing device.Upon family request, an autopsy was performed, anda massive right atrial thrombus was found filling theentire right atrium, measuring 10.3 cm 8 cm 3 cm(Figure 1). Additionally, this thrombus extended proxi-mally into the superior vena cava and distally into the rightventricle. Pacemaker leadwireswere discovered and foundto have contributed to thrombus formation. Prior rightventricular infarction was also found, as well as an oldinferiorwall infarction. The cause of deathwas determinedto be the atrial thrombus secondary to pacemaker wirewithensuing obstructive sequelae.DISCUSSIONClinically silent pacemaker lead thrombosis occurs in asmany as 35e45%of all implants; however, serious compli-cations from this aremuch rarer (1). Presenting complaintsand clinical presentations vary and include: chest pain, cy-anosis, edema, pyrexia, malaise, congestive heart failure,shortness of breath, and frank shock (5). Diagnosis is gen-erally made via echocardiogram, which can demonstrateright atrial enlargement and hyperechoic masses in theright atrium (6). Thrombi are often seen with transthoracicechocardiography (echo), but transesophageal echo hasgreater sensitivity (3). Bedside transthoracic echo is prob-ably the most appropriate initial diagnostic test, due to itseasy availability and lack of dependence on patient stabil-ity. Cardiac computed tomography scan and cardiac mag-netic resonance imaging have not been validated yet forthis purpose (7). Treatment ranges from anticoagulationor thrombolysis to surgical removal. In the majority ofcases, surgical removal has been the recommended andsuccessful treatment, but anticoagulation, thrombolysis,and percutaneous extraction have been used with somesuccess (7,8). Due to the rarity of this condition,treatment has not been extensively studied. Managementdecisions must be made on a case-by-case basis, but ifa thrombus is detected, immediate cardiothoracic surgeryand cardiology consultation is warranted. Anticoagula-tion is more likely to be considered in the stable patient.Factors predisposing individuals to development of pace-maker lead thrombosis include congestive heart failureand hypercoagulable states (2). Diagnosis is rarely madein the ED, because it is such a rare condition with a non-specific clinical presentation.Due to this patient’s hemodynamic compromise andsize of the thrombus, surgical removal probably wouldhave been the only treatment. However, the broad differ-ential diagnosis engendering the clinical presentation(that included hyperkalemia, acute coronary syndrome,digoxin toxicity, pericardial effusion, pneumonia), cou-pled with the patient’s rapid decompensation, wouldhave made surgical thrombectomy extremely difficult toperform in a way that would affect the patient’s outcome.Figure 1. Postmortem photograph showing the large rightatrial thrombus and pacer wires.e186 A. C. Feuchter and K. D. KatzDownloaded for Anonymous User (n/a) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on June 27, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.CONCLUSIONAtrial thrombus is an important diagnosis to consider in thesetting of non-specific cardiopulmonary complaints orunexplained hemodynamic compromise in a patient withan implanted pacemaker/AICD. Rapid bedside ultrasoundor early cardiology consultation and bedside echocardio-gram may be warranted in similar patients, especiallyif initial and typical diagnostics are unrevealing.REFERENCES1. Barakat K, Robinson N, Spurrell R. Transvenous pacing lead-induced thrombosis: a series of cases with a review of the literature.Cardiology 2000;93:142e8.2. Schifter D, Kozer L, Saul B, et al. An unusual case of multiple rightatrial thrombi in a patient with a dual-chambered pacemaker. Angiol-ogy 1999;50:855e8.3. Tugcu A, Ozlem Y, Tayyareci Y, et al. Right atrial pacemaker leadthrombosis causing tricuspid inflow obstruction. Pacing Clin Electro-physiol 2009;32:262e4.4. Ikonomidis I, Papadopoulos C, Flevari P, et al. Left atrial thrombusafter biventricular pacemaker implantation. Eur J Echocardiogr2009;10:582e4.5. Coleman D, DeBarr D, Morales D, et al. Pacemaker lead thrombosistreated with atrial thrombectomy and biventricular pacemaker anddefibrillator insertion. Ann Thorac Surg 2004;78:e83e4.6. Parravicini R, Cocconcelli F, Barchetti M, et al. Massive thrombosison right atrial pacemaker electrode. Tex Heart Inst J 1996;23:185.7. Carda R, Almerı́a C, Lennie V, et al. What to do with an atrial throm-bus? Eur J Echocardiogr 2008;1:204e5.8. Fabijanic D, Giunio L, Vujicic I, et al. Right atrial pacemaker leadthrombosis incidentally detected by transesophageal echocardiogra-phy. Coll Antropol 2005;29:159e61.Right Atrial Thrombus e187Downloaded for Anonymous User (n/a) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on June 27, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.

Right atrial thrombus secondary to pacemaker wires.

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Right atrial thrombus secondary to pacemaker wires.

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