*2.3.3 Pacemaker-mediated angina*

In patients who have underlying coronary artery disease, angina can be precipitated secondary to rapid pacing [64]. Usually, pacemakers are programmed to minimize right ventricular pacing. However, dual-chamber pacemakers tract the atrial electrical activity and the ventricular pacing follows. Hence, in patients with a high sinus rate or atrial tachycardia, the right ventricle could be paced at a higher rate, thereby resulting in demand ischemia [65, 66]. In the setting of underlying clinical or subclinical coronary artery disease, this in turn can lead to angina. This presents as a classical anginal form of chest pain. This can be identified by altering the pacemaker rate. Treatment typically involves reprogramming the device

**53**

*Practical Approach to Chest Pain Related to Cardiac Implantable Electronic Device Implantation*

to minimize right ventricular pacing and eventually taking care of the underlying

Patients who underwent CRT-D implantation may have a 3–6 week delayed onset of chest pain; this is more pericardial in nature and similar to Dressler syndrome. The main differentiating factor from delayed pericardial effusion/pericardial tamponade is that there is no pericardial fluid in this situation [68]. The pathogenesis of post cardiac injury syndrome is immune mediated. Imazio et al. proposed diagnostic criteria for post cardiac injury syndrome with at least two out of five

*DOI: http://dx.doi.org/10.5772/intechopen.92743*

coronary artery disease [67].

**Figure 3.**

being required [69].

corticosteroids.

1.Unexplained fever

2.Pleuritic or pericardial chest pain

4.New or worsening pericardial/pleural effusion on imaging

These patients respond very well to high-dose of aspirin, colchicine, or oral

Painful left bundle branch block (LBBB) syndrome is one of the uncommon delayed conditions seen with CIED placement [70]. Patients who have right ventricular pacemaker will have left bundle branch block morphology when pacing the

5.Elevated inflammatory markers including CRP

*2.3.5 Painful left bundle branch block syndrome*

3.Pericardial rub on auscultation

*2.3.4 Post cardiac injury syndrome*

*Cardiac implantable electronic device erosion.*

*Practical Approach to Chest Pain Related to Cardiac Implantable Electronic Device Implantation DOI: http://dx.doi.org/10.5772/intechopen.92743*

**Figure 3.** *Cardiac implantable electronic device erosion.*

*Differential Diagnosis of Chest Pain*

nerve [58, 59].

**2.3 Delayed onset chest pain**

*2.3.2 Delayed cardiac perforation*

*2.3.3 Pacemaker-mediated angina*

*2.3.1 Surgical site pain*

interpreted as chest discomfort/hiccups, manifesting predominantly in certain position [53]. For a CRT device, the coronary sinus lead would be placed into the posterolateral or lateral branches which would abut the lateral wall of the left ventricle [54, 55]. The left phrenic nerve runs very close toward the lateral border of the left ventricle. Hence, this lead could be pacing the phrenic nerve and producing diaphragmatic contractions. Usually, during lead placement, high output pacing will be performed from the coronary sinus lead to rule out any phrenic nerve capture. However, secondary to displacement of the leads, it is possible that the leads can move and capture the phrenic nerve leading on to diaphragmatic contractions [56]. The right ventricular lead typically does not produce diaphragmatic pacing except in the following situations: (1) perforation of the right ventricle and migration of the lead inferiorly to produce direct capture of the diaphragm; (2) extreme RV dilation to the extent that the lateral border of the cardiac silhouette is situated near the right ventricular apex [57]. These situations require lead revision. On the other hand, the right-sided phrenic nerve travels along the lateral border of the right atrium, distant from the right atrial appendage, and can lead to diaphragmatic pacing if the right atrial lead becomes dislodged and captures the right phrenic

In most patients, surgical site chest pain would resolve within a week or so. However, some patients may have prolonged, local chest discomfort secondary to increased sensitivity. Other conditions including superficial device placement leading on to pressure on the skin (usually at the margin of the device), nerve entrapment, hematoma, allergic reactions, erosion, infection, etc., have to be ruled out [35–40]. Depending upon the etiology, we may have to open the pocket again and

Delayed cardiac perforation secondary to CIED leads is uncommon when compared to acute perforation [60–62]. Patients will typically have symptoms of chest pain and the clinical presentation may not be as dramatic as an acute perforation. Hence a high degree of clinical suspicion needs to be maintained and early imaging including X-ray, echocardiogram, and, if needed, CT scan could be beneficial in these patients [62]. Further, device interrogation may show loss of capture, even at high output. Often these patients may need a multi-disciplinary approach including

In patients who have underlying coronary artery disease, angina can be precipitated secondary to rapid pacing [64]. Usually, pacemakers are programmed to minimize right ventricular pacing. However, dual-chamber pacemakers tract the atrial electrical activity and the ventricular pacing follows. Hence, in patients with a high sinus rate or atrial tachycardia, the right ventricle could be paced at a higher rate, thereby resulting in demand ischemia [65, 66]. In the setting of underlying clinical or subclinical coronary artery disease, this in turn can lead to angina. This presents as a classical anginal form of chest pain. This can be identified by altering the pacemaker rate. Treatment typically involves reprogramming the device

address the primary reason for the chest pain (**Figure 3**).

electrophysiologists and cardiothoracic surgeons [63].

**52**

to minimize right ventricular pacing and eventually taking care of the underlying coronary artery disease [67].

#### *2.3.4 Post cardiac injury syndrome*

Patients who underwent CRT-D implantation may have a 3–6 week delayed onset of chest pain; this is more pericardial in nature and similar to Dressler syndrome. The main differentiating factor from delayed pericardial effusion/pericardial tamponade is that there is no pericardial fluid in this situation [68]. The pathogenesis of post cardiac injury syndrome is immune mediated. Imazio et al. proposed diagnostic criteria for post cardiac injury syndrome with at least two out of five being required [69].


These patients respond very well to high-dose of aspirin, colchicine, or oral corticosteroids.

#### *2.3.5 Painful left bundle branch block syndrome*

Painful left bundle branch block (LBBB) syndrome is one of the uncommon delayed conditions seen with CIED placement [70]. Patients who have right ventricular pacemaker will have left bundle branch block morphology when pacing the right ventricle. On electrocardiography, this can be differentiated from an acute LBBB using the six criteria outlined by Shvilkin et al. [70]: abrupt onset of chest pain coinciding with the development of LBBB; simultaneous resolution of symptoms with resolution of LBBB; normal 12-lead ECGs before and after LBBB; absence of myocardial ischemia during functional stress testing; normal left ventricular function and the absence of other abnormalities to explain symptoms; and low precordial S/T wave ratio consistent with new-onset LBBB (<1.8 in this series) and inferior QRS axis.

Most of the patients tolerate right ventricular pacing without any significant clinical features. However, a small population of patients may develop significant chest pain, independent of coronary artery disease [71, 72]. Although the underlying mechanism is unclear, several mechanisms have been postulated: (1) dyssynchronous ventricular contraction occur due to paradoxical septal movement during ventricular pacing, (2) there is abnormal activation of the neurons responsible for interception ventricular pacing, and (3) there is microvascular ischemia during ventricular pacing as noted by elevated concentration of lactic acid in the coronary sinus [73–75]. A careful history and observation of chest pain only during right ventricular pacing is the clue to the correct diagnosis. Treatment of these patients is very challenging but patients may respond very well to either CRT therapy or His bundle pacing [74, 76–78].

## **3. Conclusion**

Almost all the patients that undergo CIED implantation will have some sort of chest pain dependent on the time of occurrence (**Table 1**). Most of the time this is secondary to surgical site pain. However, this could also be secondary to multiple reasons including life-threatening complications. Hence, early diagnosis and prompt treatment is warranted to minimize morbidity and mortality.


**55**

**Author details**

Umashankar Lakshmanadoss1

1 Mercy Heart Institute, Cincinnati, OH, USA

3 Cambridge International School, Dubai, UAE

provided the original work is properly cited.

\*Address all correspondence to: drlumashankar@gmail.com

*Practical Approach to Chest Pain Related to Cardiac Implantable Electronic Device Implantation*

\*, Imran Sulemankhil<sup>2</sup>

2 Department of Medicine, Jewish Hospital of Cincinnati, Cincinnati, OH, USA

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

and Karnika Senthilkumar3

*DOI: http://dx.doi.org/10.5772/intechopen.92743*

#### **Table 1.**

*Chest pain occurrence after cardiac implantable electronic device.*

### **Conflict of interest**

The authors declare no conflict of interest.

*Practical Approach to Chest Pain Related to Cardiac Implantable Electronic Device Implantation DOI: http://dx.doi.org/10.5772/intechopen.92743*
