Case Study: Leadless Pacemaker in a Patient with Parkinson’s Disease and Syncope

This case presents a 65-year-old male patient with a history of Parkinson's disease, systematic hypertension, and neuro-psychiatric illness, who was experiencing involuntary movements in both hands and feet. The patient was brought to the emergency department after a syncopal episode, prompting immediate medical evaluation.

Initial Presentation and Diagnosis

Upon arrival at the emergency department, the patient's vitals were as follows:

Blood Pressure: 110/70 mmHg

Pulse: Around 35 beats per minute (indicative of bradycardia)

SPO2: 94%

An ECG showed evidence of intermittent complete heart block (CHB), and non-contrast CT of the brain was performed to rule out any acute cerebrovascular accident, given his syncopal episode. Since the patient had known neuropsychiatric illness with involuntary movements, tolerating a temporary pacemaker was not feasible. Additionally, the patient's relatives refused the temporary pacemaker due to his condition.

Evaluation of Bradycardia

The medical team undertook a thorough investigation to rule out reversible causes of bradycardia, such as electrolyte imbalances and thyroid dysfunction, both of which were found to be normal. Troponin T levels were negative, ruling out a myocardial infarction. An echocardiogram revealed a left ventricular ejection fraction (LVEF) of 60%, which is within the normal range, and there was no regional wall motion abnormality (RWMA).

Considering these findings, the bradycardia was deemed non-reversible, and the patient was advised to undergo the implantation of a leadless permanent pacemaker due to his inability to tolerate a temporary pacemaker.

Leadless Pacemaker Implantation

The decision to use a leadless pacemaker was particularly suited for this patient given his neuropsychiatric illness and involuntary movements, which could interfere with the leads in a conventional pacemaker. Leadless pacemakers are a novel advancement in cardiac care, particularly useful in patients with contraindications to traditional pacing systems. Unlike conventional pacemakers, leadless pacemakers are self-contained devices that do not require leads to be placed in the heart. This minimizes the risk of lead-related complications, which is crucial for patients with movement disorders like Parkinson's disease.

To further ensure the patient's safety, a coronary angiography was performed prior to the procedure to confirm normal coronary arteries. This step was necessary to rule out any underlying coronary artery disease that could complicate the patient's condition or the pacemaker implantation.

The leadless pacemaker was implanted successfully. However, post-procedure, the patient developed hypotension with a systolic blood pressure of 70 mmHg and bradycardia. At this point, the heart rate was maintained at 60 beats per minute.

Postoperative Complications and Management

An immediate echocardiogram was performed due to the development of hypotension and bradycardia, which revealed a large pericardial effusion with evidence of cardiac tamponade. Cardiac tamponade is a life-threatening condition where fluid accumulation in the pericardial sac compresses the heart, preventing it from functioning properly.

In response to this emergent complication, the medical team performed an urgent pericardiocentesis, draining approximately 200 ml of hemorrhagic fluid from the pericardial sac. This procedure successfully relieved the tamponade, allowing the heart to resume normal function.

Following pericardiocentesis, the patient's condition stabilized. He was closely monitored in the hospital, and over the next few days, he recovered without further complications.

Discharge and Outcome

The patient was discharged in stable condition after several days of observation. No further complications were reported, and the leadless pacemaker continued to function effectively, maintaining an adequate heart rate and preventing future syncopal episodes.

The choice of a leadless pacemaker in this case was crucial to the patient's recovery. Leadless pacemakers offer several advantages, including a lower risk of infection, absence of leads that could be displaced due to involuntary movements, and quicker recovery time.

Discussion and Conclusion

This case highlights the complexity of managing patients with multiple comorbidities, particularly those with neuropsychiatric conditions like Parkinson's disease. The patient's inability to tolerate a temporary pacemaker due to involuntary movements and his neuropsychiatric illness posed significant challenges. The decision to use a leadless pacemaker provided an effective solution, reducing the risks associated with conventional pacing systems.

The development of postoperative cardiac tamponade following the implantation of a pacemaker, although rare, underscores the importance of continuous monitoring and rapid intervention in high-risk cases. The successful drainage of the pericardial effusion and the patient's subsequent recovery emphasize the value of a multidisciplinary approach to managing such complex cases.

In conclusion, the use of leadless pacemaker technology offers a promising alternative for patients with movement disorders or other contraindications to traditional pacemaker systems. This case demonstrates the efficacy of this approach in managing bradycardia in a high-risk patient population, leading to a positive long-term outcome.