The implantable cardioverter defibrillator (ICD) was approved for general use in the United States in 1985 1. Although most current devices employ transvenously placed endocardial leads, earlier devices utilized epicardial electrodes placed by thoracotomy. We describe a case of a bronchomediastinal fistula caused by an epicardial ICD patch electrode.
In March 2005, a 63 year old male presented with hemoptysis of approximately 100 mL of fresh blood while taking warfarin and aspirin. His past history included coronary artery disease requiring coronary artery bypass grafting, congestive heart failure and ventricular arrhythmias. An ICD with epicardial leads was placed in 1987 and revised several times subsequently. In 1999 he received a new ICD with transvenous endocardial leads. The epicardial electrodes from the earlier device were not removed. Physical examination revealed a temperature of 38.2 C°, an irregularly irregular heart rhythm and diminished breath sounds at the left lung base. His International Normalized Ratio was 2.34. A chest radiograph showed numerous mediastinal wires and a lingular infiltrate that was not seen on a prior radiograph from October 2003. Anticoagulation was discontinued, and antibiotic therapy was initiated. A CT scan of the chest showed an air collection in the left mediastinum and multiple mediastinal wires (figure 1). Fiberoptic bronchoscopy revealed a pair of wires eroding into the medial wall of the lingular bronchus with an associated bronchial defect that opened and closed dynamically with breathing (figure 2). The patient was referred for surgery. A thoracotomy revealed an epicardial patch electrode eroding into the lingular bronchus. The left upper lobe was resected but the offending electrode could not be removed from the epicardium because of extensive fibrosis. He tolerated the surgery well but suffered a cardiopulmonary arrest of unclear etiology on post-operative day 7. His neurological status did not recover, and ventilatory support was withdrawn 8 days later.
Epicardial placement of ICD electrodes via thoracotomy has been largely supplanted by transvenous placement of endocardial leads, which is associated with shorter recovery times and lower perioperative mortality rates.1 However, in some patients transvenous lead placement is not possible, and many patients received devices prior to the development of transvenous methods. Therefore, physicians should remain aware of the potential complications of epicardial ICD electrodes. We report a patient who developed a fistula between the lingular bronchus and the mediastinum many years after an epicardial patch electrode was placed. Two similar cases have been reported. Lick and Conti 2 described a patient who developed an infected cavitary lesion from an extrapericardial patch electrode that had eroded into the lingular bronchus. He was treated successfully with surgical removal of the electrode, closure of the bronchial defect, and antibiotics. Dasgupta et al3 described a patient in whom an epicardial patch electrode had migrated into the left lower lobe of the lung. The patient was treated successfully with lobectomy, patch electrode removal, and antibiotics. In cases such as these, surgical intervention is necessary to prevent chronic infection.
Epicardial ICD electrodes may occasionally migrate and erode into adjacent structures, even many years after initial placement. Erosion into a bronchus can cause hemoptysis and chronic infection. Surgical removal of the electrode and closure of the bronchial defect is indicated when possible.
James Driscoll, None.