Redo Sternotomy for the Removal of an Epicardial Pacemaker Wire Causing Life Impairment Symptoms

A 44-year-old male with a complex cardiac history presented to the hospital with persistent abdominal contractions that interfered with both breathing and speech. His cardiac history dated back to the age of 15 when he underwent surgical repair of an atrioventricular (AV) canal defect. The procedure was complicated by complete heart block, necessitating the implantation of a pacemaker with epicardial leads and an abdomen generator. At the age of 27, he received a new dual-chamber pacemaker with endocardial leads. Shortly after that, he began experiencing abdominal contractions, which continued for 15 years and eventually prompted him to seek medical help at the authors institution. The new endocardial lead system was speculated to be the cause of his symptoms. Despite many trials of repositioning the endocardial leads, the patient’s symptoms endured without any improvement, and the abdominal pulsations did not terminate. An electrophysiology study with temporary pacemaker electrodes placed at different heart sites with various amplitudes indicated no resolution of the abdominal contraction; however, the contraction rate decreased with the reduction of the pacing heart rate. It was clearly concluded that the patient’s symptoms were due to the abandoned epicardial pacemaker wires, not the endocardial lead as previously anticipated. 

A minimally invasive surgical procedure was performed, during which the old epicardial lead was found to be severely adhered to the rectus abdominis muscle. A segment of the lead was carefully dissected and trimmed, while the remaining tip was capped and isolated. The patient experienced symptomatic improvement following the procedure, although the contractions were not completely resolved. 
 
Surgical Techniques 

Upon reentry through the sternum during redo surgery, dense adhesions were noted involving all surfaces of the heart. Meticulous adhesiolysis was performed, particularly along the diaphragmatic surface of the right ventricle. A coil was found forming a dense, adherent mass attached to the cardiac surface. The inferior coil and its associated screw had developed into a calcified mass firmly fixed to the heart. 

The coil was carefully dissected and released from the cardiac surface down to the inferior lobe and the screw. Decalcification was performed, and all coils were excised using scissors. The remaining screw was completely encased in calcified tissue. To prevent any potential electrical conduction to the diaphragm, an additional protective layer consisting of a Dacron patch and BioGlue was applied. 

Comments 

By performing an off-pump dissection of the epicardial pacemaker wire and leaving the screw embedded within the myocardium with additional coverage, the authors believe this technique offers a more reliable and less invasive alternative to cardiopulmonary bypass and screw excision, which may be more disruptive to the myocardium. 

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