- Email: [email protected]
Persistent Left Superior Vena Cava Complicating Pacemaker Catheter Insertion
396
GARCIA ET AL
8 Onoyama K, Tanaka K: Fibrinolytic activity of the arterial wall. Thromb Diath Haemorrh 21 : I, 1969 9 Stefanini M, Marin H : Fibrinolysis. I. Fibrinolytic activity of extracts from nonpathogenic fungi. Proc Soc Exp Bioi Med 99 :504, 1958 10 Young RC, Bennett JE, Vogel CL , et al : Aspergillosis. The spectrum of the disease in 98 patients. Medicine 49: 147, 1970 11 Slavin RG, Stanczyk OJ, Lonigro AJ, et al : Allergic bronchopulmonary aspergillosis-a North American rarity. Amer J Med 47:306,1969 12 Seabury JH, Samuels M: The pathogenic spectrum of aspergillosis. Amer J Clin Path 40 :21, 1963 13 Astrup T: The biological significance of fibrinolysis. Lancet 2 :565, 1956
Persistent Left Superior Vena Cava Complicating Pacemaker Catheter Insertion* Leonda Garcia, M.D .;oO Richard S. Levine, M.D ., F.C.C.P.;o Warren Kossowsky, M.D.;t and Alan F. Lyon, M.D .~
Transvenous pacemaker therapy was complicated by the presence of a persistent left superior vena cava and absence of the right superior vena cava. The correct diagnosis was made during life by venous angiography and enabled successful therapy to be instituted utiUzing the transthoracic placement of pacemaker electrodes. The transvenous catheter technique for pacemaker therapy of complete heart block has met with widespread acceptance, sin ce its clinical introduction in 1958,1 Complications associated with its use have included infection, cardiac perforation, ventricular fibrillation, pulmonary emboli, and failure to pace due to catheter tip dlsplacement," Recently, a case was reported in which pacemaker failure and death was believed to occur secondary to catheter tip displacement due to anomalous venous return to the heart. 3 This report describes a patient, requiring a pacemaker, in whom a similar venous anomaly was recognized during life . The transthoracic approach to pacemaker implantation was utilized successfully. CASE REPORT
The patient, a 79-year-old white woman, was first seen at The Brookdale Hospital Center in 1968. She had had a slow heart rat e for many years . Three years prior to admission, she had collapsed and pacemaker therapy was advised. The patient refused and was placed on isoproterenol tablets three °From the Department of Medicine, The Brookdale Hospital Medical Center, Brooklyn, New York. ° °Assistant Attending Physician . tAssistant Professor of Clinical Medicine, New York University. tAssociate Professor of Clinical Medicine, New York University . Reprint requests: Dr. Levine , Brookdale Hospital Medical Center, Brooklyn 11212
FICURE 1. Pacemaker catheter entering heart through persistent left superior vena cava. times per day . Since then , the pulse rate had generally remained slow, but she also experienced episodes of paroxysmal rapid heart beating. These latter episodes were associated with dyspnea and angina pectoris . Just prior to admission she had an attack of syncope and fell down a flight of stairs. Physical Examination: The blood pressure was 140/90. The pulse rate was slow, varying between 35 and 40, and was occasionally irregular. The neck veins were distended and hepato-jugular reflux was present. The lungs were clear to auscultation. The heart was not enlarged and no gallop or murmur was detected. There was moderate pretibial edema. The electrocardiogram showed sinus bradycardia with a rate varying between 30 and 40. There were occasional premature nodal ventricular contractions. Atrial activity was occasionally absent and there was A-V nodal escape rhythm. The initial chest x-ray film showed no abnormalities of the heart or lungs. The aorta was widened and calcified on chest roentgenogram. A demand type transvenous catheter pacemaker was inserted through the left cephalic vein. The catheter course was noted by the surgeon to be atypical and persistent left superior vena cava was suspected at that time. Although some difficulty in manipulation was noted, the catheter was passed down the left cava, through the coronary sinus and into the right atrium. From there is was deflected off the lateral wall of the atrium and into the right ventricle where effective pacing was obtained (Fig 1) . The QRS complex on the electrocardiogram demonstrated the expected left bundle branch block pattern. Th e pati ent was discharged from the hospital and apparently did well for 23 months when she again noted slow pulse rate and experienced marked dizziness. She was readmitted and the electrocardiogram showed ineffective pacemaker activity at a very slow rate with an underlying sinus bradycardia varying with atrial standstill and a nodal escape rhythm. The pacemaker battery pack was replaced by the surgeon, but under fluoroscopy, it was noted that the catheter tip was no longer located within the right ventricle. Attempts at manipulating the permanent catheter were repeatedly unsuccessful but a more rigid, No.7, temporary pacemaker catheter was introduced through the previously described route followed by effective pacing . An angiogram was per-
CHEST, VOL. 61, NO.4, APRIL, 1972
397
GLOMERULONEPHRITIS FOLLOWING STREPTOCOCCAL PNEUMONIA
FIGURE 2. Angiogram showing absence of the right superior ven a cava . formed via a right arm vein demonstrating absent right superior vena cava. All of the venous return from the upper half of the body entered the right atrium through the persistent left superior vena cava and coronary sinus (Fig 2). These findings and persistence of the patient's symptoms prompted us to implant the pacemaker electrodes utilizing the transthoracic approach. This was successful and postoperative electrocardiogram demonstrated effective pacing from the left ventricle (Fig 3). No further complications were encountered and the patient is asymptomatic one year later.
Our case would appear to present similar anatomic findings which were recognized during life and successful therapy instituted by the transthoracic route of implantation. While our patient was paced successfully for 23 months initially, we would agree with Kukral that the catheter position attained through the tortuous course presented by this set of anatomic relationships is tenuous at best. When a pacemaker catheter, passed from the left side, fails to pass the midline and enters the right heart via persistent left superior vena cava, an alternate method of therapy should be sought. In an emergency situation where temporary pacing is required immediately, a femoral vein approach" may be utilized to bypass the venous anomalies above the diaphragm. The anatomy of the superior vena cava may be investigated by angiography performed from the right arm or right external jugular vein . A normal superior vena cava properly communicating with the right atrium, would indicate placement of a permanent transvenous pacemaker through the right cephalic vein . The transthoracic approach would appear to offer one satisfactory alternative in the presence of an additional right superior vena caval anomaly. REFERENCES
2 3 4
DISCUSSION
Most of the previous clinical literature concerning persistent left superior vena cava has discussed the difficulties encountered in cardiac catheterization - and during cardiac surgery. 5 The only discussion of persistent left superior vena cava complicating pacemaker therapy was presented by Kukral ." In his case, sudden death followed shortly after pacemaker implantation and autopsy examination dem onstrated a persistent left superior vena cava entering the right atrium through the coronary sinus with only a trophic remnant of the right superior vena cava. The cause of death was believed to be loss of capture due to pacemaker tip displacement.
5 6
Furman S, Robinson G: The use of an intracardiac pacemaker in correction of total heart block. Surg Forum 9:245, 1958 Furman S : Complications of pacemaker therapy for heart block. Amer j CardioI17:439-442, 1966 Kukral jC : Transvenous pacemaker failure due to anomalous venous return to the heart. Chest 59 :458-461, 1971 Fraser RS, Dvorkin J, Rosall RE, et a1: Left superior vena cava. A review of associated congenital heart lesions, 'catheterization data and roentgenologic findings . Amer J Med 31:711-715,1961 Hurwitt E : The surgical importance of a persistent left superior vena cava . Arch Dis Childhood 34 :1-4, 1959 Solomon N, Escher DJW : A rapid method for insertion of the pacemaker catheter electrode. Amer Heart J 66 :717718,1963
Glomerulonephritis following Streptococcal Pneumonia * David A. Levinson, M.D.,oO and Kenneth D. Litwack, M.D.t
A case of glomerulonephritis following streptococcal pneumonia in an elderly man is described. The importance of considering the Streptococcus in the dillerential diagnosk of bacterial pneumonias is stressed. The nonsuppurative compUcation of this pneumonia is documented.
FIGURE 3. ECG rhythm strip prior to and after institution of pacemaker therapy.
CHEST, VOL. 61, NO.4, APRIL, 1972
°From the United States Public Health Service Hospital, San Francisco. 00 Assistant Resident in Medicine. tChief, Infectious Disease Service. Reprint requests: Director, PHS Hospital, 15th Avenue and Lake Street, San Francisco 94118
GARCIA ET AL
8 Onoyama K, Tanaka K: Fibrinolytic activity of the arterial wall. Thromb Diath Haemorrh 21 : I, 1969 9 Stefanini M, Marin H : Fibrinolysis. I. Fibrinolytic activity of extracts from nonpathogenic fungi. Proc Soc Exp Bioi Med 99 :504, 1958 10 Young RC, Bennett JE, Vogel CL , et al : Aspergillosis. The spectrum of the disease in 98 patients. Medicine 49: 147, 1970 11 Slavin RG, Stanczyk OJ, Lonigro AJ, et al : Allergic bronchopulmonary aspergillosis-a North American rarity. Amer J Med 47:306,1969 12 Seabury JH, Samuels M: The pathogenic spectrum of aspergillosis. Amer J Clin Path 40 :21, 1963 13 Astrup T: The biological significance of fibrinolysis. Lancet 2 :565, 1956
Persistent Left Superior Vena Cava Complicating Pacemaker Catheter Insertion* Leonda Garcia, M.D .;oO Richard S. Levine, M.D ., F.C.C.P.;o Warren Kossowsky, M.D.;t and Alan F. Lyon, M.D .~
Transvenous pacemaker therapy was complicated by the presence of a persistent left superior vena cava and absence of the right superior vena cava. The correct diagnosis was made during life by venous angiography and enabled successful therapy to be instituted utiUzing the transthoracic placement of pacemaker electrodes. The transvenous catheter technique for pacemaker therapy of complete heart block has met with widespread acceptance, sin ce its clinical introduction in 1958,1 Complications associated with its use have included infection, cardiac perforation, ventricular fibrillation, pulmonary emboli, and failure to pace due to catheter tip dlsplacement," Recently, a case was reported in which pacemaker failure and death was believed to occur secondary to catheter tip displacement due to anomalous venous return to the heart. 3 This report describes a patient, requiring a pacemaker, in whom a similar venous anomaly was recognized during life . The transthoracic approach to pacemaker implantation was utilized successfully. CASE REPORT
The patient, a 79-year-old white woman, was first seen at The Brookdale Hospital Center in 1968. She had had a slow heart rat e for many years . Three years prior to admission, she had collapsed and pacemaker therapy was advised. The patient refused and was placed on isoproterenol tablets three °From the Department of Medicine, The Brookdale Hospital Medical Center, Brooklyn, New York. ° °Assistant Attending Physician . tAssistant Professor of Clinical Medicine, New York University. tAssociate Professor of Clinical Medicine, New York University . Reprint requests: Dr. Levine , Brookdale Hospital Medical Center, Brooklyn 11212
FICURE 1. Pacemaker catheter entering heart through persistent left superior vena cava. times per day . Since then , the pulse rate had generally remained slow, but she also experienced episodes of paroxysmal rapid heart beating. These latter episodes were associated with dyspnea and angina pectoris . Just prior to admission she had an attack of syncope and fell down a flight of stairs. Physical Examination: The blood pressure was 140/90. The pulse rate was slow, varying between 35 and 40, and was occasionally irregular. The neck veins were distended and hepato-jugular reflux was present. The lungs were clear to auscultation. The heart was not enlarged and no gallop or murmur was detected. There was moderate pretibial edema. The electrocardiogram showed sinus bradycardia with a rate varying between 30 and 40. There were occasional premature nodal ventricular contractions. Atrial activity was occasionally absent and there was A-V nodal escape rhythm. The initial chest x-ray film showed no abnormalities of the heart or lungs. The aorta was widened and calcified on chest roentgenogram. A demand type transvenous catheter pacemaker was inserted through the left cephalic vein. The catheter course was noted by the surgeon to be atypical and persistent left superior vena cava was suspected at that time. Although some difficulty in manipulation was noted, the catheter was passed down the left cava, through the coronary sinus and into the right atrium. From there is was deflected off the lateral wall of the atrium and into the right ventricle where effective pacing was obtained (Fig 1) . The QRS complex on the electrocardiogram demonstrated the expected left bundle branch block pattern. Th e pati ent was discharged from the hospital and apparently did well for 23 months when she again noted slow pulse rate and experienced marked dizziness. She was readmitted and the electrocardiogram showed ineffective pacemaker activity at a very slow rate with an underlying sinus bradycardia varying with atrial standstill and a nodal escape rhythm. The pacemaker battery pack was replaced by the surgeon, but under fluoroscopy, it was noted that the catheter tip was no longer located within the right ventricle. Attempts at manipulating the permanent catheter were repeatedly unsuccessful but a more rigid, No.7, temporary pacemaker catheter was introduced through the previously described route followed by effective pacing . An angiogram was per-
CHEST, VOL. 61, NO.4, APRIL, 1972
397
GLOMERULONEPHRITIS FOLLOWING STREPTOCOCCAL PNEUMONIA
FIGURE 2. Angiogram showing absence of the right superior ven a cava . formed via a right arm vein demonstrating absent right superior vena cava. All of the venous return from the upper half of the body entered the right atrium through the persistent left superior vena cava and coronary sinus (Fig 2). These findings and persistence of the patient's symptoms prompted us to implant the pacemaker electrodes utilizing the transthoracic approach. This was successful and postoperative electrocardiogram demonstrated effective pacing from the left ventricle (Fig 3). No further complications were encountered and the patient is asymptomatic one year later.
Our case would appear to present similar anatomic findings which were recognized during life and successful therapy instituted by the transthoracic route of implantation. While our patient was paced successfully for 23 months initially, we would agree with Kukral that the catheter position attained through the tortuous course presented by this set of anatomic relationships is tenuous at best. When a pacemaker catheter, passed from the left side, fails to pass the midline and enters the right heart via persistent left superior vena cava, an alternate method of therapy should be sought. In an emergency situation where temporary pacing is required immediately, a femoral vein approach" may be utilized to bypass the venous anomalies above the diaphragm. The anatomy of the superior vena cava may be investigated by angiography performed from the right arm or right external jugular vein . A normal superior vena cava properly communicating with the right atrium, would indicate placement of a permanent transvenous pacemaker through the right cephalic vein . The transthoracic approach would appear to offer one satisfactory alternative in the presence of an additional right superior vena caval anomaly. REFERENCES
2 3 4
DISCUSSION
Most of the previous clinical literature concerning persistent left superior vena cava has discussed the difficulties encountered in cardiac catheterization - and during cardiac surgery. 5 The only discussion of persistent left superior vena cava complicating pacemaker therapy was presented by Kukral ." In his case, sudden death followed shortly after pacemaker implantation and autopsy examination dem onstrated a persistent left superior vena cava entering the right atrium through the coronary sinus with only a trophic remnant of the right superior vena cava. The cause of death was believed to be loss of capture due to pacemaker tip displacement.
5 6
Furman S, Robinson G: The use of an intracardiac pacemaker in correction of total heart block. Surg Forum 9:245, 1958 Furman S : Complications of pacemaker therapy for heart block. Amer j CardioI17:439-442, 1966 Kukral jC : Transvenous pacemaker failure due to anomalous venous return to the heart. Chest 59 :458-461, 1971 Fraser RS, Dvorkin J, Rosall RE, et a1: Left superior vena cava. A review of associated congenital heart lesions, 'catheterization data and roentgenologic findings . Amer J Med 31:711-715,1961 Hurwitt E : The surgical importance of a persistent left superior vena cava . Arch Dis Childhood 34 :1-4, 1959 Solomon N, Escher DJW : A rapid method for insertion of the pacemaker catheter electrode. Amer Heart J 66 :717718,1963
Glomerulonephritis following Streptococcal Pneumonia * David A. Levinson, M.D.,oO and Kenneth D. Litwack, M.D.t
A case of glomerulonephritis following streptococcal pneumonia in an elderly man is described. The importance of considering the Streptococcus in the dillerential diagnosk of bacterial pneumonias is stressed. The nonsuppurative compUcation of this pneumonia is documented.
FIGURE 3. ECG rhythm strip prior to and after institution of pacemaker therapy.
CHEST, VOL. 61, NO.4, APRIL, 1972
°From the United States Public Health Service Hospital, San Francisco. 00 Assistant Resident in Medicine. tChief, Infectious Disease Service. Reprint requests: Director, PHS Hospital, 15th Avenue and Lake Street, San Francisco 94118