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An unusual chest radiograph in a patient with implantable cardioverter-defibrillator: How was this device implanted?
An unusual chest radiograph in a patient with implantable cardioverter-defibrillator: How was this device implanted? Aditya Saini, MD, Kenneth A. Ellenbogen, MD, FHRS From the Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia. A 74-year-old woman with chronic systolic heart failure and recurrent syncope with inducible sustained monomorphic ventricular tachycardia underwent implantation of a single-chamber implantable cardioverter-defibrillator (ICD) in 2004. She had a history of breast cancer treated remotely with mastectomy, axillary lymph node dissection, radiation, and chemotherapy. Her chest radiograph with posteroanterior (PA) and lateral views is shown in Figure 1. How was this device implanted?
Case report The PA view (Figure 1, left panel) demonstrates an unusual course of the dual-coil defibrillator lead and an inferiorly
Figure 1
located device generator (arrowhead). The lateral view is required to further define the course of the ICD lead. This is better shown in the right panel of the figure. The lead terminates in the right ventricle (RV) and appears to be in the RV apex, and though the distal coil (DC) is intracardiac, the proximal coil (PC) does not appear to be intracardiac or intravascular. In fact, the lead does not appear to be entering the heart via the superior vena cava but seems to be penetrating the cardiac silhouette directly at the level of the anterior right atrium. Another important observation is that the proximal coil is outside the cardiac silhouette and appears to be in the subcutaneous or submuscular layer of the chest wall. In addition, multiple surgical clips from prior chest surgery are noted in the right lateral chest wall and axilla, and
Chest radiograph PA (left panel) and lateral view (right panel) from our patient. See text for discussion.
Address reprint requests and correspondence: Dr Aditya Saini, Division of Cardiology, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA 23298-0053. E-mail address: dradityasaini@ gmail.com.
2214-0271 B 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.hrcr.2016.12.006
Saini and Ellenbogen
Unusual Chest Radiograph in Patient With an ICD
KEY TEACHING POINTS The described image illustrates the importance of
chest radiograph as a key imaging tool for cardiac electrophysiologists and health care practitioners taking care of patients with defibrillators. It is important to recognize unusual device
implantation techniques through chest radiograph analysis and be able to put this information into correct clinical context in deciding the appropriate next step in patient management. It is vital to recognize the significance of correct
positioning of the implantable cardioverterdefibrillator lead to maximize success of defibrillation by ensuring an appropriate shock vector. a couple of surgical clips are also seen on the right anterior chest. Our review of records from the outside hospital where the ICD was implanted indicated that the patient had an unsuccessful attempt at implantation of a transvenous ICD system owing to inaccessible and occluded central veins related to prior radiation therapy and chest surgery. The device was implanted surgically via a right anterior thoracotomy at the level of the third costal cartilage. The right
193
pleural cavity was entered after excision of a segment of the third rib. Pericardiotomy was performed and the right atrium was accessed through the appendage, followed by implantation of a 58-cm dual-coil ICD lead in the RV apex delivered through an 11F introducer sheath. The lead was secured at the right atrial appendage insertion site by purse-string sutures and was then tunneled submuscularly over to the ICD generator, which in turn was implanted in a subfascial pocket in the left lower chest.
Discussion What issues are expected with device functioning in this patient? The RV is an anterior cardiac structure, and optimum defibrillator lead positioning to achieve an appropriate shock vector for successful defibrillation is critical. The major concern with this implant is the inferiorly located pulse generator and the fact that the proximal coil is in subcutaneous tissue in the anterior chest rather than a more posterior location. Although sensing of VT/VF should be normal because the RV lead tip is in an appropriate position, there is a possibility of unsuccessful defibrillation. A subcutaneous ICD would be an ideal device for this patient in current times. All lead parameters tested within normal limits in this patient. The patient had no defibrillation threshold testing at time of surgical implantation; however, defibrillation threshold testing was performed at the time of a subsequent generator change in 2012 and VF was successfully detected and treated by the ICD.
Case report The PA view (Figure 1, left panel) demonstrates an unusual course of the dual-coil defibrillator lead and an inferiorly
Figure 1
located device generator (arrowhead). The lateral view is required to further define the course of the ICD lead. This is better shown in the right panel of the figure. The lead terminates in the right ventricle (RV) and appears to be in the RV apex, and though the distal coil (DC) is intracardiac, the proximal coil (PC) does not appear to be intracardiac or intravascular. In fact, the lead does not appear to be entering the heart via the superior vena cava but seems to be penetrating the cardiac silhouette directly at the level of the anterior right atrium. Another important observation is that the proximal coil is outside the cardiac silhouette and appears to be in the subcutaneous or submuscular layer of the chest wall. In addition, multiple surgical clips from prior chest surgery are noted in the right lateral chest wall and axilla, and
Chest radiograph PA (left panel) and lateral view (right panel) from our patient. See text for discussion.
Address reprint requests and correspondence: Dr Aditya Saini, Division of Cardiology, Virginia Commonwealth University Medical Center, P.O. Box 980053, Richmond, VA 23298-0053. E-mail address: dradityasaini@ gmail.com.
2214-0271 B 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.hrcr.2016.12.006
Saini and Ellenbogen
Unusual Chest Radiograph in Patient With an ICD
KEY TEACHING POINTS The described image illustrates the importance of
chest radiograph as a key imaging tool for cardiac electrophysiologists and health care practitioners taking care of patients with defibrillators. It is important to recognize unusual device
implantation techniques through chest radiograph analysis and be able to put this information into correct clinical context in deciding the appropriate next step in patient management. It is vital to recognize the significance of correct
positioning of the implantable cardioverterdefibrillator lead to maximize success of defibrillation by ensuring an appropriate shock vector. a couple of surgical clips are also seen on the right anterior chest. Our review of records from the outside hospital where the ICD was implanted indicated that the patient had an unsuccessful attempt at implantation of a transvenous ICD system owing to inaccessible and occluded central veins related to prior radiation therapy and chest surgery. The device was implanted surgically via a right anterior thoracotomy at the level of the third costal cartilage. The right
193
pleural cavity was entered after excision of a segment of the third rib. Pericardiotomy was performed and the right atrium was accessed through the appendage, followed by implantation of a 58-cm dual-coil ICD lead in the RV apex delivered through an 11F introducer sheath. The lead was secured at the right atrial appendage insertion site by purse-string sutures and was then tunneled submuscularly over to the ICD generator, which in turn was implanted in a subfascial pocket in the left lower chest.
Discussion What issues are expected with device functioning in this patient? The RV is an anterior cardiac structure, and optimum defibrillator lead positioning to achieve an appropriate shock vector for successful defibrillation is critical. The major concern with this implant is the inferiorly located pulse generator and the fact that the proximal coil is in subcutaneous tissue in the anterior chest rather than a more posterior location. Although sensing of VT/VF should be normal because the RV lead tip is in an appropriate position, there is a possibility of unsuccessful defibrillation. A subcutaneous ICD would be an ideal device for this patient in current times. All lead parameters tested within normal limits in this patient. The patient had no defibrillation threshold testing at time of surgical implantation; however, defibrillation threshold testing was performed at the time of a subsequent generator change in 2012 and VF was successfully detected and treated by the ICD.