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Dual-chamber pacemaker implantation in a CoreValve recipient with a persistent left superior vena cava
International Journal of Cardiology 166 (2013) 519–549
Contents lists available at SciVerse ScienceDirect
International Journal of Cardiology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d
Letters to the Editor
Dual-chamber pacemaker implantation in a CoreValve recipient with a persistent left superior vena cava Polychronis Dilaveris ⁎, Skevos Sideris, Konstantinos Toutouzas, Konstantinos Gatzoulis, Christodoulos Stefanadis 1st University Department of Cardiology, Hippokration Hospital, Athens, Greece
a r t i c l e
i n f o
Article history: Received 31 July 2012 Accepted 22 September 2012 Available online 6 October 2012 Keywords: Bicuspid aortic valve TAVI pacemaker implantation persistent left superior vena cava
A high risk 68-year-old female with severe symptomatic stenosis of a bicuspid aortic valve (BAV) underwent successful implantation of transcatheter aortic valve (TAVI) (CoreValve™ 26 mm, Medtronic, Minneapolis, Minnesota). Because permanent complete atrioventricular (AV) block developed during TAVI, the patient was referred for dual-chamber pacemaker implantation. A left-sided pectoral implantation was attempted. The presence of a persistent left superior vena cava (PLSVC) leading to a dilated coronary sinus was incidentally found during advancement of the guide wire from the left subclavian vein to the superior vena cava and was subsequently verified on venography (Fig. 1A). Thereafter, a long (65 cm) active fixation lead was manipulated to enter the right ventricle by the use of the wide loop technique [1] and fixed in the ventricular wall (Fig. 1B). A second
⁎ Corresponding author at: 22, Miltiadou Str., 15561 Athens, Greece. Tel./fax: + 30 2106531377. E-mail address: [email protected] (P. Dilaveris).
0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2012.09.144
lead was screwed-in the atrial wall (Fig. 1C). Finally, the temporary pacing lead was removed, and the pacemaker implantation was completed uneventfully (Fig. 1D and E). BAV is the most common congenital cardiovascular anomaly, occurring in 1% to 2% of the population. It usually occurs in isolation, but it may be associated with other abnormalities, such as coarctation of the aorta and patent ductus arteriosus. More rarely, BAV is associated with PLSVC [2]. BAV stenosis reportedly comprises 30% to 50% of all adult patients undergoing aortic valve replacement surgery for severe aortic stenosis [3]. Although BAV has generally been considered to contraindicate TAVI, selected high-risk patients with BAV stenosis can be successfully treated with TAVI [3]. Valve-related AV block requiring pacemaker implantation is a frequent finding after TAVI [4]. The development of intraoperative AV block, as in our patient, signifies a higher need for permanent pacemaker implantation [4]. When the presence of a PLSVC is anticipated, specific manoeuvres should be applied to facilitate lead manipulation and suitable positioning. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. References [1] Dilaveris P, Sideris S, Stefanadis C. Pacing difficulties due to persistent left superior vena cava. Europace Jan 2011;13(1):2. [2] Goyal SK, Punnam SR, Verma G, Ruberg FL. Persistent left superior vena cava: a case report and review of literature. Cardiovasc Ultrasound Oct 10 2008;6:50 (Review). [3] Wijesinghe N, Ye J, Rodés-Cabau J, et al. Transcatheter aortic valve implantation in patients with bicuspid aortic valve stenosis. JACC Cardiovasc Interv Nov 2010;3(11):1122–5. [4] Khawaja MZ, Rajani R, Cook A, et al. Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve Collaborative). Circulation 2011;123(9):951–60.
520
Letters to the Editor
Fig. 1. Pacing through a persistent left superior vena cava in a CoreValve recipient.(A) The presence of a persistent left superior vena cava leading to a dilated coronary sinus was verified on venography. (B) A long active-fixation lead was manipulated to enter the right ventricle and fixed in the ventricular wall. (C) A second lead was screwed-in the atrial wall. (D and E) Frontal and lateral chest X-ray views showing the final position of the pacemaker system. Black arrow: temporary pacing lead inserted through the right jugular vein.
Contents lists available at SciVerse ScienceDirect
International Journal of Cardiology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d
Letters to the Editor
Dual-chamber pacemaker implantation in a CoreValve recipient with a persistent left superior vena cava Polychronis Dilaveris ⁎, Skevos Sideris, Konstantinos Toutouzas, Konstantinos Gatzoulis, Christodoulos Stefanadis 1st University Department of Cardiology, Hippokration Hospital, Athens, Greece
a r t i c l e
i n f o
Article history: Received 31 July 2012 Accepted 22 September 2012 Available online 6 October 2012 Keywords: Bicuspid aortic valve TAVI pacemaker implantation persistent left superior vena cava
A high risk 68-year-old female with severe symptomatic stenosis of a bicuspid aortic valve (BAV) underwent successful implantation of transcatheter aortic valve (TAVI) (CoreValve™ 26 mm, Medtronic, Minneapolis, Minnesota). Because permanent complete atrioventricular (AV) block developed during TAVI, the patient was referred for dual-chamber pacemaker implantation. A left-sided pectoral implantation was attempted. The presence of a persistent left superior vena cava (PLSVC) leading to a dilated coronary sinus was incidentally found during advancement of the guide wire from the left subclavian vein to the superior vena cava and was subsequently verified on venography (Fig. 1A). Thereafter, a long (65 cm) active fixation lead was manipulated to enter the right ventricle by the use of the wide loop technique [1] and fixed in the ventricular wall (Fig. 1B). A second
⁎ Corresponding author at: 22, Miltiadou Str., 15561 Athens, Greece. Tel./fax: + 30 2106531377. E-mail address: [email protected] (P. Dilaveris).
0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2012.09.144
lead was screwed-in the atrial wall (Fig. 1C). Finally, the temporary pacing lead was removed, and the pacemaker implantation was completed uneventfully (Fig. 1D and E). BAV is the most common congenital cardiovascular anomaly, occurring in 1% to 2% of the population. It usually occurs in isolation, but it may be associated with other abnormalities, such as coarctation of the aorta and patent ductus arteriosus. More rarely, BAV is associated with PLSVC [2]. BAV stenosis reportedly comprises 30% to 50% of all adult patients undergoing aortic valve replacement surgery for severe aortic stenosis [3]. Although BAV has generally been considered to contraindicate TAVI, selected high-risk patients with BAV stenosis can be successfully treated with TAVI [3]. Valve-related AV block requiring pacemaker implantation is a frequent finding after TAVI [4]. The development of intraoperative AV block, as in our patient, signifies a higher need for permanent pacemaker implantation [4]. When the presence of a PLSVC is anticipated, specific manoeuvres should be applied to facilitate lead manipulation and suitable positioning. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. References [1] Dilaveris P, Sideris S, Stefanadis C. Pacing difficulties due to persistent left superior vena cava. Europace Jan 2011;13(1):2. [2] Goyal SK, Punnam SR, Verma G, Ruberg FL. Persistent left superior vena cava: a case report and review of literature. Cardiovasc Ultrasound Oct 10 2008;6:50 (Review). [3] Wijesinghe N, Ye J, Rodés-Cabau J, et al. Transcatheter aortic valve implantation in patients with bicuspid aortic valve stenosis. JACC Cardiovasc Interv Nov 2010;3(11):1122–5. [4] Khawaja MZ, Rajani R, Cook A, et al. Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve Collaborative). Circulation 2011;123(9):951–60.
520
Letters to the Editor
Fig. 1. Pacing through a persistent left superior vena cava in a CoreValve recipient.(A) The presence of a persistent left superior vena cava leading to a dilated coronary sinus was verified on venography. (B) A long active-fixation lead was manipulated to enter the right ventricle and fixed in the ventricular wall. (C) A second lead was screwed-in the atrial wall. (D and E) Frontal and lateral chest X-ray views showing the final position of the pacemaker system. Black arrow: temporary pacing lead inserted through the right jugular vein.