Kalıcı Kalp Pili İmplantasyonu Sonrası Geç Dönem Bir Komplikasyon: Hasta Tarafından Yerinden Oynatılmış Batarya ve Sistemin Çıkartılması
Özet
Kalıcı kalp pili (KKP) implantasyonu semptomatik bradiaritmilerin tedavisinde günümüzde güvenli ve etkili bir yöntemdir. Teknolojideki gelişmeler ve implantasyon tekniklerindeki ilerlemeler komplikasyon oranlarını azaltmış olsa da cihaz ilişkili sorunlar günümüzde hâlâ önemli bir morbidite nedeni olmaya devam etmektedir. Self-inflicted extraction, tanımı hastanın bilinçli veya bilinçsiz olarak cihazı manipüle etmesi sonucunda ortaya çıkan nadir ancak ciddi bir komplikasyonu tanımlar. Bu durum sıklıkla Twiddler, Reel ve Ratchet sendromları spektrumunda değerlendirilmektedir. Klasik olgularda lead dislokasyonu, pacing kaybı ve uygunsuz cihaz fonksiyonları ön planda iken bazı hastalarda lead pozisyonları korunmasına rağmen jeneratör ekstrüzyonu gelişebilmektedir. Bu yazıda intermittan tam atriyoventriküler blok nedeniyle DDDR kalıcı kalp pili implante edilen ve ileri derecede demans öyküsü bulunan 81 yaşındaki hastada implantasyondan 1 yıl sonra gelişen self-inflicted generator extrusion olgusu sunulmaktadır. Hastada lead pozisyonları korunmasına rağmen jeneratörün cilt dışına ekstrüde olduğu saptanmış, enfeksiyon riski nedeniyle sistem ekstraksiyonu uygulanmıştır. Başlangıçta yeniden implantasyon yapılmayan hasta üç ay sonra tekrar tam atriyoventriküler blok ile başvurmuş ve sağ pektoral bölgeden yeniden DDDR kalıcı kalp pili implantasyonu gerçekleştirilmiştir. Bu olgu, cihaz manipülasyonu, demans ve geç dönem cihaz komplikasyonları arasındaki ilişkiyi göstermesi açısından dikkat çekicidir. Ayrıca jeneratör ekstrüzyonu gelişen hastalarda sistem ekstraksiyonu ve yeniden implantasyon kararlarının bireyselleştirilmesi gerektiğini ortaya koymaktadır.
Permanent pacemaker (PPP) implantation is currently a safe and effective method for treating symptomatic bradyarrhythmias. Although advances in technology and implantation techniques have reduced complication rates, device-related problems remain a significant cause of morbidity. Self-inflicted extraction is a rare but serious complication resulting from the patient's conscious or unconscious manipulation of the device. This condition is often evaluated within the spectrum of Twiddler, Reel, and Ratchet syndromes. While classic cases primarily involve lead dislocation, loss of pacing, and inappropriate device function, some patients may develop generator extrusion despite preserving lead positions. This article presents a case of self-inflicted generator extrusion that occurred one year after implantation in an 81-year-old patient with advanced dementia who had received a DDDR permanent pacemaker implantation due to intermittent complete atrioventricular block. Despite preserving lead positions, the generator was found to have extruded outside the skin, and system extraction was performed due to the risk of infection. The patient, who initially did not undergo reimplantation, presented again three months later with complete atrioventricular block and underwent reimplantation of a permanent DDDR pacemaker via the right pectoral region. This case is noteworthy for demonstrating the relationship between device manipulation, dementia, and late-stage device complications. It also highlights the need for individualization of system extraction and reimplantation decisions in patients who develop generator extrusion.
Referanslar
Glikson, M., Nielsen, J. C., Kronborg, M. B., Michowitz, Y., Auricchio, A., Barbash, I. M., ark. (2021). 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, 42(35), 3427–3520. https://doi.org/10.1093/eurheartj/ehab364
Kirkfeldt, R. E., Johansen, J. B., Nohr, E. A., Jørgensen, O. D., & Nielsen, J. C. (2014). Complications after cardiac implantable electronic device implantations: An analysis of a complete, nationwide cohort in Denmark. European Heart Journal, 35(18), 1186–1194. https://doi.org/10.1093/eurheartj/eht511
Udo, E. O., Zuithoff, N. P., van Hemel, N. M., de Cock, C. C., Hendriks, T., Doevendans, P. A., ark. (2012). Incidence and predictors of short- and long-term complications in pacemaker therapy: The FOLLOWPACE study. Heart Rhythm, 9(5), 728–735. https://doi.org/10.1016/j.hrthm.2011.12.014
Bayliss, C. E., Beanlands, D. S., & Baird, R. J. (1968). The pacemaker-twiddler's syndrome: A new complication of implantable transvenous pacemakers. Canadian Medical Association Journal, 99(8), 371–373.
Nicholson, W. J., Tuohy, K. A., & Tilkemeier, P. (2003). Twiddler's syndrome. New England Journal of Medicine, 348(17), 1726–1727. https://doi.org/10.1056/NEJMicm020170
Carnero-Varo, A., Pérez-Paredes, M., Ruiz-Ros, J. A., Giménez-Cervantes, D., Martínez-Corbalán, F. R., Cubero-López, T., ark. (1999). 'Reel syndrome': A new form of twiddler's syndrome? Circulation, 100(8), e45–e46. https://doi.org/10.1161/01.CIR.100.8.e45
Von Bergen, N. H., Atkins, D. L., Gingerich, J. C., & Law, I. H. (2007). 'Ratchet' syndrome, another etiology for pacemaker lead dislodgement: A case report. Heart Rhythm, 4(6), 788–789. https://doi.org/10.1016/j.hrthm.2006.12.029
Liang, J. J., & Fenstad, E. R. (2013). Twiddler's syndrome. Lancet, 382(9888), e47. https://doi.org/10.1016/S0140-6736(13)61171-5
Mandal, S., Pande, A., & Kahali, D. (2012). A rare case of very early pacemaker Twiddler's syndrome. Heart Views, 13(3), 114–115. https://doi.org/10.4103/1995-705X.102158
Navarro-Gonzalez, J., Durán Caamaño, M., Lara Pedreros, C., & Sepulveda, K. (2024). A case of twiddler's syndrome: A rare complication of pacemakers. Cureus, 16(10), e71923. https://doi.org/10.7759/cureus.71923
Burri, H., Starck, C., Auricchio, A., Biffi, M., Birgersdotter-Green, U., Boriani, G., ark. (2021). EHRA expert consensus statement and practical guide on optimal implantation technique for conventional pacemakers and ICDs. Europace, 23(6), 983–1008. https://doi.org/10.1093/europace/euaa367
Stuart, R., Gilbert, Z., & Valencia, D. N. (2020). Erosive Twiddler's syndrome: A severe case with externalization of the pacemaker. Cureus, 12(3), e7458. https://doi.org/10.7759/cureus.7458
de la Guia-Galipienso, F., de la Guia-Fayos, M., Lopez-Aranda, M. A., Simon-Machi, J. M., & Quesada-Dorador, A. (2024). Reel versus Twiddler syndrome in a patient with a pacemaker: A case report of iatrogenic manipulation. Cureus, 16(7), e65758. https://doi.org/10.7759/cureus.65758
Salahuddin, M., Cader, F. A., Nasrin, S., & Chowdhury, M. Z. (2016). The pacemaker-twiddler's syndrome: An infrequent cause of pacemaker failure. BMC Research Notes, 9, 32. https://doi.org/10.1186/s13104-016-1843-z
Rossignon, P., Tajildin, R., & Famdie, E. (2025). Twists and turns: CRT-D with mixed Twiddler and Reel syndromes. Netherlands Heart Journal, 33(2), 67–68. https://doi.org/10.1007/s12471-024-01924-z
Johansen, J. B., Jørgensen, O. D., Møller, M., Arnsbo, P., Mortensen, P. T., & Nielsen, J. C. (2011). Infection after pacemaker implantation: Infection rates and risk factors associated with infection in a population-based cohort study of 46,299 consecutive patients. European Heart Journal, 32(8), 991–998. https://doi.org/10.1093/eurheartj/ehq497
Kusumoto, F. M., Schoenfeld, M. H., Wilkoff, B. L., Berul, C. I., Birgersdotter-Green, U. M., Carrillo, R., ark. (2017). 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm, 14(12), e503–e551. https://doi.org/10.1016/j.hrthm.2017.09.001
Bongiorni, M. G., Burri, H., Deharo, J. C., Starck, C., Kennergren, C., Saghy, L., ark. (2018). 2018 EHRA expert consensus statement on lead extraction. Europace, 20(7), 1217. https://doi.org/10.1093/europace/euy050
Wilkoff, B. L., Love, C. J., Byrd, C. L., Bongiorni, M. G., Carrillo, R. G., Crossley, G. H., ark. (2009). Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management. Heart Rhythm, 6(7), 1085–1104. https://doi.org/10.1016/j.hrthm.2009.05.020
Bongiorni, M. G., Kennergren, C., Butter, C., Deharo, J. C., Kutarski, A., Rinaldi, C. A., ark. (2017). The European Lead Extraction ConTRolled (ELECTRa) study. Europace, 19(3), 523–529. https://doi.org/10.1093/europace/euw130
Kusumoto, F. M., Vijayaraman, P., Ellenbogen, K. A., Niazi, I., Beaser, A. D., Tung, R., ark. (2023). 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing. Heart Rhythm, 20(9), e17–e91. https://doi.org/10.1016/j.hrthm.2023.03.1538
Osoro, M., Molto, J. M., Ruiz-Granell, R., Ferrero, A., & García-Civera, R. (2018). Twiddler syndrome: A comprehensive review. Pacing and Clinical Electrophysiology, 41(10), 1410–1416. https://doi.org/10.1111/pace.13460
