Inadvertent Left Ventricle Endocardial or Uncomplicated Right Ventricular Pacing: How to Differentiate in the Emergency Department

Background

Temporary transvenous pacemaker implantation is an important and critical procedure for emergency physicians. Traditionally, temporary pacemakers are inserted by electrocardiography (ECG) guidance in the emergency department because fluoroscopy at the bedside in an unstable patient can be limited by time and equipment availability. However, in the presence of atrial septal defect, ventricular septal defect, and patent foramen ovale, the pacemaker lead can be implanted inadvertently into the left ventricle or directly into the coronary sinus instead of right ventricle. Regular pacemaker rhythm can be achieved despite inadvertent implantation of the pacemaker lead into the left ventricle, leading to ignorance of the possibility of lead malposition.

Noncompaction of ventricular myocardium: A study of twelve patients

We report 12 patients with ventricular noncompaction who were echocardiographically identified at our institution since 1991. The mean age at presentation was 3.5 years. Five patients had isolated noncompaction. Three of them had subnormal left ventricular systolic function at presentation. Noncompaction was associated with complex congenital heart defect in 3 patients. Four patients had simple congenital heart defects: pulmonary stenosis, coarctation of aorta with aberrant origin of right subclavian artery, ventricular septal defect, and partial anomalous pulmonary venous return. The observed rhythm abnormalities were Wolff-Parkinson-White syndrome and paroxysmal supraventricular tachycardia, bigemini ventricular extrasystoles, and left bundle branch block. A transvenous pacemaker was implanted in a patient because of complete heart block. Noncompaction of the ventricular myocardium is rare. Our patients clearly represent the clinical and morphological spectrum of this disorder. Distinct morphological features can be diagnosed on 2-dimensional echocardiography.     

Acute hypoxia due to right to left blood shunting in a patient with atrial septal defect

Acute right to left blood shunt is an unusual cause of acute hypoxia. We describe a case of a patient with an atrial septal defect who developed acute hypoxia due to cardiac tamponade. Acute haemopericardium developed as a complication of temporary transvenous cardiac pacing. Bubble contrast echocardiography confirmed right to left blood shunting at the atrial level. Acute hypoxaemia and the right to left blood shunt resolved when the pericardium was drained. The case underscores the importance of evaluating the presence of an intracardial shunt in patients with otherwise inexplicable hypoxia.     

Biventricular Pacing Using Two Pacemakers and the Triggered VVT Mode

O'COCHLAIN, B., et al. : Biventricular Pacing Using Two Pacemakers and the Triggered VVT Mode. Pacemaker dependent patients exhibit interventricular conduction delay due to right ventricular lead placement. The addition of a transvenous coronary sinus lead for biventricular pacing has been shown to be effective. Venous stenosis and thrombosis postpacemaker implantation can occur in up to 35% of patients. This report describes a patient with a preexisting left-sided dual chamber pacemaker and chronic left subclavian vein occlusion that was upgraded to a biventricular system by placing a coronary sinus lead and single chamber ventricular triggered pacemaker on the opposite side.     

Extraction of Chronically Infected Transvenous Pacemaker Leads: Report of an Unusual Problem

This is a report of a patient with an impacted, chronically infected transvenous pacemaker lead whose management was complicated by the presence of a functioning contralateral transvenous pacemaker. Treatment included sustained traction on the infected lead, a left subcostal thoracofomy for placement of new sutureless epicardial leads, and retrograde right iliac vein cannula-tion for final snare removal of the mobilized lead. The patient is currently free of infection, and has normal pacemaker function.     

Amaurosis Fugax in a Patient with a Left Ventricular Endocardial Pacemaker

A transvenous left ventricular endocardial pacemaker catheter is a potential source of systemic arterial embolization. The case of a woman who presented with left-eye amaurosis fugax is reported. The patient had a history of contralateral carotid atherosclerosis; however, the digital subtraction angiography of the carotid arteries was not sufficiently abnormal to account for her present symptoms. The patient had a history of two myocardial infarctions and the tachycardia-bradycardia syndrome for which she was treated with a demand ventricular pacemaker. The chest x-ray and electrocardiogram suggested pacemaker catheter malposition. By M-mode and two-dimensional echocardiography, the catheter was shown to cross the atrial septum and the mitral valve to implant in the left ventricular endocardium. The approach to diagnosis and therapy that led to surgical removal of the pacing catheter is presented. The causes of the electrocardiographic right bundle branch block pattern in cardiac pacing and the usefulness of echocardiography in evaluating pacing catheters are discussed.     

Transvenous pacemaker placement: left lateral decubitus position and wireless digital radiography

A patient presented with symptomatic third degree atrioventricular block requiring emergency transvenous pacemaker placement. During the procedure, wireless digital radiographs tracked the position of the pacemaker electrode, which repeatedly missed the target right ventricle. The patient was then rolled to left lateral decubitus position and the electrode was advanced into the right ventricle, achieving electrical capture, hemodynamic stability, and symptom resolution. We review the published literature on transvenous pacemaker placement and identify two innovations: left lateral decubitus position to facilitate catheter placement and wireless digital radiography for procedure guidance.     

Assessment of intracardiac anomalies in two adults with Ivemark's syndrome.

Ivemark's syndrome consists of intracardiac anomalies, abnormal lobation of the lungs, and abdominal heterotaxy. A frequent intracardiac anomaly seen in Ivemark's syndrome is a common atrium, which is associated with left-to-right shunting. The increased blood flow and resistance within the pulmonary vasculature creates pulmonary hypertension and eventual reversal of the shunt physiology. In the absence of additional cyanotic malformations, survival into adulthood without prior surgical septation of the common atrium depends on the extent of pulmonary hypertension and intracardiac right-to-left shunting. We present two patients with a common atrium in the setting of Ivemark's syndrome who survived into adulthood without prior operation. Two-dimensional echocardiography assessed their intracardiac structures. One patient had right atrial isomerism manifested by asplenia and a common atrium, into which the hepatic veins drained directly, and the other patient had left atrial isomerism manifested by polysplenia, a common atrium, and a ventricular septal defect with a single atrioventricular valve. Neither patient had additional cyanotic malformations, including obstruction to pulmonary venous return, transposition of the great vessels, or pulmonic valve stenosis. The 2-dimensional echocardiogram guides the clinician to refer patients for surgical septation of the common atrium before the right-to-left shunt physiology predominates. The medical and surgical treatment of these patients is discussed.     

室间隔缺损修补术后残余分流自然愈合的彩色多普勒超声心动图观察

本文报道２例室间隔缺损修补术后残余分流但以后自然愈合的患者，１例室间隔缺损患者于修补术后１０天彩色多普勒超声心动图检查时见残余分流，在术后１２周复查时发现残余分流自然消失。另１例为室间隔缺损合并房间隔缺损患者，术后第２天有较重的血红蛋白尿，彩色多普勒超声心动图检查时发现心室水平及左室与右房间的残余分流而行再次修补术。第二次术后１５天彩色多普勒超声心动图检查时仍存在左室与右房间的残余分流。继续追踪观察于再次术后７周原残余分流消失，自然愈合。室间隔缺损术后可因修补不完善，补片与空间隔间缝线撕裂，或补片与室间隔间存在较窄的缝隙而出现残余分流。较小的残余分流可因补片与室间隔交接处形成血栓、缝线周围纤维化等因素而自然愈合，患者无需进行再治疗。彩色多普勒超声心动图可较敏感地发现室间隔缺损术后残余分流，并可追踪观察残余分流的自然愈合，因而对其预后判断具有重要价值。     

Asymptomatic Left Ventricular Malposition of a Transvenous Pacemaker Lead Through a Sinus Venosus Defect: Follow-up Over 17 Years

The case of a woman with an asymptomatic transvenous left ventricular endocardial pacemaker lead is presented. The chest X ray and the electrocardiogram suggested pacemaker catheter malposition. By two-dimensional echocardiography, the pacemaker lead was shown to cross from the left atrium through the mitral valve and implant in the left ventricular endocardium. The underlying sinus venosus defect and the passage of the electrode through this interatrial communication were directly visualized by transesophageal echocardiography. No thrombotic material attached to the lead was detected corresponding to the patient's uneventful course for surprisingly more than 17 years without evidence of past or present neurological deficiencies or of peripheral embolic phenomena. Thus, no operative correction was performed. Warfarin sodium therapy, however, was initiated.     

Transvenous Dual Chamber Pacing via a Unilateral Left Superior Vena Cava

A 74-year-old woman with a unilateral left superior vena cava required dual chamber permanent pacing after a radical cardiac operation for an incomplete form of endocardial cushion defect. An active fixation ventricular lead was used to prevent the instability induced by the strange course of the electrode. For atrial pacing, a ventricular passive fixation lead was used. A transvenous dual chamber pacemaker was successfully inserted via a unilateral left superior vena cava.     

Leadless pacemaker use in a patient with a durable left ventricular assist device

There is limited known safety and efficacy of leadless pacemaker device use in patients with durable left ventricular assist devices (LVADs). We present a case of a pacemaker-dependent LVAD patient with infection of permanent transvenous pacemaker who underwent successful implantation of Micra transcatheter pacing system (Medtronic).     

Late Endocardial Pacing Lead Body Migration Compromising Fontan Physiology

Migration of intracardiac transvenous pacing leads may occur. There is a known risk of intrapul- monary ventricular pacing lead migration in patients with endocardial lead systems. In the current report we present the late intrapulmonary migration of an endocardial atrial pacing lead body. The patient had undergone antitachycardia pacemaker placement to control recurrent atrial tachyarrhythmias following the Fontan procedure. Although the lead electrode remained in place and continued to pace, the lead body migrated, causing severe obstruction to blood flow. This resulted in severe cardiac decompensation, which was ultimately ameliorated by lead repositioning.     

Early appearance of echo-contrast simulating an intracardiac shunt in a patient with liver cirrhosis and intrapulmonary shunting.

Time of appearance of agitated saline contrast in the left atrium is one of the distinguishing features between intracardiac and intrapulmonary shunt. We report a patient with hepatic cirrhosis who had intrapulmonary shunting and had appearance of peripheral venous saline contrast injection in the left heart chambers within 3 cardiac cycles after its appearance in the right heart chambers despite absence of an intracardiac shunt. Thus, time of appearance of saline contrast in the left heart chambers should not be the sole criterion to distinguish intracardiac from intrapulmonary shunt.     

Differential regulation of right and left ventricular beta-adrenergic receptors in newborn lambs with experimental cyanotic heart disease.

To determine whether chronic hypoxemia secondary to an intracardiac right-to-left shunt alters regulation of the myocardial beta-adrenergic receptor/adenylate cyclase system, we produced chronic hypoxemia in nine newborn lambs by creating right ventricular outflow obstruction and an atrial septal defect. Oxygen saturation was reduced to 65-74% for 2 wk. Eight lambs served as normoxemic controls. beta-receptor density (Bmax) and ligand affinity (KD) were determined with the radio-ligand [125I]iodocyanopindolol and adenylate cyclase activity determined during stimulation with isoproterenol, sodium fluoride (NaF), and forskolin. During chronic hypoxemia, Bmax decreased 45% (hypoxemic, 180.6 +/- 31.5 vs. control, 330.5 +/- 60.1 fmol/mg) in the left ventricle (exposed to hypoxemia alone) but was unchanged in the right ventricle (exposed to hypoxemia and pressure overload). KD was not different from control in either ventricle. Left ventricular isoproterenol-stimulated adenylate cyclase activity was decreased by 39% (30.0 +/- 4.3% increase vs. 44.1 +/- 9.5% increase) whereas right ventricular adenylate cyclase activity was unchanged. Stimulation of adenylate cyclase with NaF or forskolin was not different from control in either ventricle. Circulating epinephrine was increased fourfold whereas circulating and myocardial norepinephrine were unchanged. These data demonstrate a down-regulation of the left ventricular beta-adrenergic receptor/adenylate cyclase system during chronic hypoxemia secondary to an intracardiac right-to-left shunt.     

Permanent pacemaker lead entrapment: role of the transesophageal echocardiography

Numerous complications induced by pacemaker electrodes have been reported. Although mild tricuspid regurgitation is a well-documented complication of transvenous right ventricular pacemaker leads secondary to abnormal valve coaptation, severe tricuspid regurgitation resultingfrom perforation of the tricuspid valve itself is a rare complication. This case report details a patient with severe tricuspid regurgitation secondary to impingement of the tricuspid valve by a permanent pacing lead that was diagnosed by transesophageal echocardiography. Surgical repair was advocated because of symptomatic significant tricuspid regurgitation.     

Radiofrequency catheter ablation of an incessant ventricular tachycardia following valve surgery

Sustained monomorphic ventricular tachycardia (VT) after valve surgery represents a clinical entity with different tachycardia mechanisms. This case report describes an incessant VT after tricuspid and aortic valve replacement that did not respond to antiarrhythmic drug treatment. The tachycardia exhibited VA block and a right bundle branch block pattern with left-axis deviation, suggesting ventricular excitation via the left posterior fascicle. The electrophysiological study was limited by the prosthetic tricuspid and aortic valve replacement, therefore a transseptal approach was necessary to obtain access to the ventricular myocardium. Radiofrequency catheter ablation was performed in the proximal left bundle or distal His region with termination of the incessant VT followed by complete AV block. After pacemaker implantation using a transvenous right atrial and an epicardial ventricular lead, no VT reoccurrence could be documented.     

Extreme Intracardiac Coiling of a Transvenous Pacemaker; A Case Report

We report an unusual complication of transvenous pacing: extreme coiling of a pacemaker catheter, which formed a redundant, twisted loop protruding into the right ventricular outflow tract. This may be a result of "tividdling" (rotation) of the pacemaker generator by the patient and/or inadequate fixation of the catheter at the venous entry site. Careful fixation of the generator to the venous entry site within the subcutaneous pocket may prevent such a complication.     

Safety of Implantation of a Leadless Pacemaker via Femoral Approach in the Presence of an Inferior Vena Cava Filter

A 61‐year‐old woman with symptomatic complete heart block was referred for permanent pacemaker. The presence of a left‐sided arteriovenous fistula and right‐sided mastectomy with lymph node dissection precluded the implantation of a transvenous pacemaker, and therefore, a leadless pacemaker was recommended. The patient also had an inferior vena cava (IVC) filter. The passage of a 27‐French introducer sheath housing the leadless pacemaker through IVC filter was carefully visualized under fluoroscopy and advanced to the right ventricle without any compromise to the filter. This case report shows the safety of passage of large sheaths via the IVC filter.     

Single-lead VDD pacemaker implantation via persistent left superior vena cava: an improved technique and a new modality

Persistent left superior vena cava (PLSVC), which occurs in approximately 0.5% of the general population, may complicate pacemaker implantation by making lead insertion into the right ventricle more difficult and increasing lead instability when the transvenous approach is attempted. We describe our experience with four PLSVC patients with pacemakers. We developed an open J-loop technique in which the stylet tip is directed toward the orifice of the tricuspid valve anteroinferiorly. The lead was implanted into the right ventricular apex without difficulty. Three of our patients had high-degree atrioventricular block and received VVI pacemakers with the new technique. One patient with complete atrioventricular block received a single-lead VDD pacemaker by means of the same technique, with the paired electrodes positioned in the lower right atrium. Excellent results were obtained on exercise tolerance testing, 24-hour Holter monitoring, and echocardiographically determined systolic and diastolic function. This improved technique can simplify pacemaker implantation in patients with PLSVC. The VDD device is a new way to maintain systolic and diastolic function and is an appropriate option in patients with high-degree atrioventricular block and PLSVC who require pacemaker implantation.