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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 135-137

Use of steroid therapy as a bridge to decision-making in patients with late rising pacing threshold after pacemaker implantation?


1 Department of Cardiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of CTVS, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission21-Jun-2021
Date of Decision22-Jul-2021
Date of Acceptance22-Jul-2021
Date of Web Publication25-Aug-2021

Correspondence Address:
Dr. Shishir Soni
Building Number 85, All India Institute of Medical Sciences Campus, All India Institute of Medical Sciences, Veerbhadra Road, Rishikesh - 249 201, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_84_21

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  Abstract 


The late rising pacing threshold is an alarming situation in which a possibility of lead dislodgement is usually considered first. This condition is usually picked up on routine follow-up interrogation; however, it can clinically manifest as syncope due to bradyarrhythmia. We report such a case in a 59-year-old male presenting to the emergency with syncope with a double chamber pacemaker in situ. He had a history of pacemaker implantation 16 years back and a pulse generator replacement (PGR) 6 years back with desirable parameters found immediately and up to 4 years after PGR. He was found to have a complete heart block on an electrocardiogram following the evaluation of presyncope and subsequently on his pacemaker interrogation high threshold was found which improved to acceptable levels after 4 weeks of steroid therapy.

Keywords: Pacing threshold, steroid, Pacemaker implantation


How to cite this article:
Kumar B, Soni S, Gore P, Darbari A. Use of steroid therapy as a bridge to decision-making in patients with late rising pacing threshold after pacemaker implantation?. Heart India 2021;9:135-7

How to cite this URL:
Kumar B, Soni S, Gore P, Darbari A. Use of steroid therapy as a bridge to decision-making in patients with late rising pacing threshold after pacemaker implantation?. Heart India [serial online] 2021 [cited 2021 Dec 4];9:135-7. Available from: https://www.heartindia.net/text.asp?2021/9/2/135/324616




  Introduction Top


A massive rise in capture threshold detected on pacemaker interrogation years after pacemaker implantation usually indicates a mechanical problem either due to conductor fracture or due to insulation damage.[1],[2] There have been a few case reports mentioning elevated capture thresholds effectively treated with the use of steroids where the probable mechanism was attributed to the increased fibrosis at the tissue electrode interface.[3],[4] Herein, we report a case of a 59-year-old male with the right atrial and right ventricular (RV) leads placed 16 years back during permanent pacemaker implantation and only pulse generator replacement (PGR) done 6 years back who presented with presyncope in the emergency and was found to have a massive rise in capture threshold with normal impedance. Subsequently, temporary pacemaker implantation was done owing to the detection of complete heart block in surface electrocardiogram (ECG) and was given a trial of steroids for elevated thresholds which came down to acceptable levels on the 5th day of therapy and remained normal for more than 1-year follow-up after 1-month of steroid therapy.


  Case Report Top


A 59-year-old male, hypertensive with a history of permanent pacemaker insertion 16 years back and PGR 6 years back, presented to the emergency with frequent episodes of giddiness for 15 days without any loss of consciousness. ECG at the time of presentation showed a complete heart block with an atrial rate of 100/min and with a ventricular rate of 40/min with a pacing spike not synchronous with ECG suggesting loss of capture. The patient immediately underwent temporary pacemaker insertion under fluoroscopic guidance in the cath lab. Fluoroscopy images were also obtained to assess pacemaker lead dislodgement; however, there was no such finding. His echocardiogram suggested normal left ventricular function. Laboratory investigations including troponins and blood sugar were also normal. His pacemaker interrogation was done which showed normal impedance of the lead and increased threshold (6V) of RV lead with a battery life of 6 years. He had no history of drug intake which can potentially increase the threshold. He had no history of myocardial infarction (MI). Based on the previous case reports related to the late rise of threshold after pacemaker insertion suspecting fibrosis at RV lead end, the patient was given steroid therapy. He was given 8 mg of dexamethasone intravenously in four equally divided doses. Interrogation on the 3rd day showed a drop in threshold to 3.9V, which further got reduced to 2.2V on the 5th day of steroid therapy. The patient was discharged on the 7th day on oral steroid therapy for 1-month at tapering doses with close follow-up in outpatient department. During his follow-up visits (for 15 months), the threshold found on interrogation remained at a value <1.5V [Figure 1]. The patient is currently on regular follow-up without any symptoms.
Figure 1: Graph showing the changes in right ventricular pacing threshold over time and reduction in pacing threshold after initiation of steroid therapy (marked by red arrow)

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  Discussion Top


In this case report, a massive threshold rise was detected on the interrogation which was done to evaluate presyncope in a 59-year-old male with 16-year-old pacemaker leads and 6-year-old pulse generator. In this condition, before opting for leads replacement, a trial of steroid therapy was given suspecting fibrosis at the electrode-tissue interface which was successful in reducing thresholds to optimum levels. A combination of increased thresholds with normal impedance which was evidenced in this case can be due to lead dislodgement (unstable lead position, twiddler's syndrome), early lead maturation secondary to an inflammatory process, or late high thresholds (resulting from progressive fibrosis, damaged lead-tissue interface, and drugs).[2] In this patient, the lead position was confirmed in fluoroscopy. The patient did not receive any new drug in the past 2 years and he had normal parameters on pacemaker interrogation done 2 years back. Although only a few case reports are available mentioning the improvement with steroids in the late rise of thresholds after pacemaker implantation; however, unlike those cases, leads were placed 16 years (vs. 2–6 years in the previous case reports) back in this patient still a trial of steroids was given.[3],[4] With steroid therapy, thresholds were reduced to <2.5 V on the 5th day of steroid therapy which was consistent with the other case reports.[3],[4] Intravenous dexamethasone (equivalent to prednisolone 1 mg/kg body weight) was given for 7 days following which oral prednisolone was given and tapered off gradually over 1-month. The dose and duration of steroid therapy were similar to the other case reports; however, in a few case reports, the duration of therapy was more than 1-month.[3],[4] Improvement with steroid therapy has also been reported in such patients with associated myocarditis; however, this patient had normal left ventricular ejection fraction and had no other clues suggesting such possible etiology.[5] Blood investigation including troponin-I, creatine phosphokinase was also normal in this patient ruling out acute myocardial injury. A recent study evaluating the performance of RV pacing leads found MI and diabetes with higher fasting plasma glucose as a risk factor associated with high pacing threshold on long-term follow-up after pacemaker implantation.[6],[7] However, this patient was nondiabetic and had no history of MI. The benefit of avoiding another procedure for lead replacement should be weighed against the risk of side effects with the use of steroids. Although steroid therapy with close observation for side effects seems safe in such cases, it depends on the individual patient profile to decide the treatment plan. If the threshold would have not improved with steroid therapy in this case, then lead replacement was the viable option. Thus, steroid therapy may or may not provide benefit in every case but at least it can be used as a bridge to decision-making. A large, well-designed study can provide more insight into the use of steroids in such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Authors' contributions

BK,SS: Concept, design, definition of Intellectual content. SS,PG: Literature search, data acquisition BK,SS,AD : Analysis, Manuscript preparation, Editing.

BK,SS,PG,AD : Manuscript review

Ethical approval

Informed consent was obtained from the patient. Patient anonymity has been maintained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
  References Top

1.
Seegers J, Lüthje L, Zabel M, Vollmann D. Loss of capture late after right ventricular pacing lead revision: What is the mechanism? Clin Res Cardiol 2009;98:517-20.  Back to cited text no. 1
    
2.
Dohrmann ML, Goldschlager NF. Myocardial stimulation threshold in patients with cardiac pacemakers: Effect of physiologic variables, pharmacologic agents, and lead electrodes. Cardiol Clin 1985;3:527-37.  Back to cited text no. 2
    
3.
Ferraro A, Masi AS, Mazza A, Brusin MC, Conte MR. Increased stimulation threshold in a patient with autoimmune disease: Successful management with oral prednisolone and azathioprine. Europace 2009;11:527-9.  Back to cited text no. 3
    
4.
Nagatomo Y, Ogawa T, Kumagae H, Koiwaya Y, Tanaka K. Pacing failure due to markedly increased stimulation threshold 2 years after implantation: Successful management with oral prednisolone: A case report. Pacing Clin Electrophysiol 1989;12:1034-7.  Back to cited text no. 4
    
5.
Mitsuya N, Kishi R, Suzuki N, Tamura M, Imai Y, Tanaka O, et al. Efficacy of steroid therapy for pacing failure in a patient with chronic myocarditis. Intern Med 2004;43:213-7.  Back to cited text no. 5
    
6.
Peng H, Sun Z, Zhang H, Ma W. Long-term performance of right ventricular pacing leads: Risk factors associated with permanent right ventricular pacing threshold increase. J Interv Card Electrophysiol 2019;55:349-57.  Back to cited text no. 6
    
7.
Kistler PM, Liew G, Mond HG. Long-term performance of active-fixation pacing leads: A prospective study. Pacing Clin Electrophysiol 2006;29:226-30.  Back to cited text no. 7
    


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