Pacemaker lead fracture caused by strong lead bending in the pocket with the fixation of the generator in the low prothoracic position

Lead fractures of pacemakers can occur over time. However, the entire mechanisms or sites of lead fractures remain unclear. In addition, fixation of the pacemaker generators and leads depends on the operators and the tips on proper fixation remain unclear. A 64-year-old male underwent permanent dual-chamber pacemaker implantation for complete atrioventricular block by extrathoracic axillary vein puncture eight years previously. The generator was routinely fixed to the pectoralis major muscle within the left anterior chest pacemaker pocket by suturing a nylon ligature through the suture hole. However, five months ago, complete atrial lead failure was confirmed. The chest X-ray and X-ray fluoroscopy revealed strong lead bending of the atrial lead in the pacemaker pocket with the fixation of the generator in the low prothoracic position. We successfully extracted the fractured atrial lead by using an excimer laser and implanted a new atrial pacemaker lead in the right atrium. In the extraction of the fractured atrial lead, the atrial lead was almost disconnected along with strong lead bending in the pacemaker pocket as expected from preprocedural X-rays. This report indicates the precautions in fixation of pacemaker leads in the pacemaker pocket.

Learning objective

The stress-free fixation of pacemaker leads should be cautious to avoid the risk of lead failure in the long-term after the procedure. In addition, less tortuous vascular lead path, more caudal can location, and large angle of lead exit from the pocket associated with the puncture site or angle of axillary vein in the pacemaker implantation can cause strong lead bending and lead fractures. These findings can be detected in the X-ray.