Successful retrieval of J-guidewire from right atrium accidentally dislodged during temporary pacing

摘要

Introduction: Conduction system disorder is one of the leadingcause of morbidity and mortality in India specially in the easternpart. Most of the patients present to the emergency departmentwith bradycardia and asystole and they need to be treated immediatelyby temporary pacemaker implantation followed by implantationof permanent pacemaker. Although fluoroscopy is neededfor the very purpose, but sometimes due to emergency situationtemporary transvenous pacemaker are implanted without fluoroscopyat bedside Guidewire-associated complications can occurduring the process of sheath insertion, eg: kinking, looping, andknotting. Rarely the wire can be dislodged in the vasculature,where it can cause vessel damage, major hemorrhage, or embolizationto vital structures. We report a case of J-guidewire dislodgedaccidentally to the right atrium. The guidewire wassuccessfully withdrawn with the help of a pigtail catheter underfluoroscopic guidance. The patient remained hemodynamicallystable throughout the procedure. In this way, we averted an opensurgical procedure.Case report: A 65-year-old diabetic male, known case of CAD, postCABG presented with 2 episodes of syncope to the emergencydepartment. His pulse was 20/min and BP was 40 mmHg (systolic).ECG showed complete heart block. As the cathlab was occupied byongoing procedure, so, temporary pacemaker was implantedthrough femoral vein immediately after admission at the bedsideand patient became stable. Next day, he was taken to cathlab forpermanent pacemaker implantation. On OT table, when wechecked the position of temporary pacemaker lead, we were surprisedto see that the short J-guidewire is present inside the heart;curved upper end being at the top of right atrium. To avoid opencardiac surgery, we decided to retrieve the wire under fluoroscopicguidance. Unfortunately snare was not available, so we tried toapply some ideas so that it can be removed under fluoroscopy.First, we removed the temporary pacemaker lead as the patientwas in sinus rhythm at that time. Then, we tried to insert a longfemoral sheath over the lower end of the J-wire with the intent toinsert a PTCA wire and balloon and subsequently to remove thewire by inflating the balloon and pressing the wire against theinner wall of the sheath. But we failed in the first step. Then, wetried with a handmade snare out of a PTCA wire; again we failed.Next, we inserted another J-wire and tried to wrap it around thedislodged wire; but whenever, we tried to pull it, it slipped away.Finally, we introduced a 5 F pigtail catheter, and wrapped it aroundthe J-wire. With gentle pull, it came down from right atrium andthe lower end engaged in femoral vein. With a small incision overfemoral vein, we removed the J-wire and we averted an opensurgical procedure.Discussion: Complete heart block with syncope is one of theimportant cardiac emergency and need to treated with immediatetransvenous temporary pacemaker implantation. Although temporarypacemaker lead implantation is a simple procedure, oneshould be extremely careful. Preferably, it should be done in thecathlab. Depending upon personal preferences, it can be donethrough femoral, jugular and subclavian vein. After the procedure,one should always check that the needle, J-wire, dilator is discarded.Snare should always be available at the cathlab. Innovativeideas can avert many complications. One should have patienceduring any complication.