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PP-351 CORONARY VENOUS ANGIOPLASTY TO A RING LIKE STRICTURE PREVENTING LEFT VENTRICULAR LEAD INSERTION: A CASE REPORT
Posters / International Journal of Cardiology 155S1 (2012) S129–S227
Methods: After preparation and under sterile conditions, we were unable to engage the coronary sinus ostium from a puncture in the left subclavian vein. Atrial and ventricular leads were placed in the usual fashion from the left site (Figure 1A). We moved to the right site to get an access to the right subclavian vein and this time were able to place the coronary sinus lead in a lateral branch (Figure 1B). Then, a subcutaneous tunnel over the sternum was created to pull the coronary sinus lead to the left site adjacent to the other leads. The leads were connected to a CRT-D and were all implanted in a left infraclavicular surgical pocket (Figure 1A). No complications were encountered (Figure 1C). Conclusions: A difficulty with coronary sinus engagement sometimes occurs in CRT-(D) implantation. We demonstrate that gaining access in the contralateral site with subcutaneus, presternal tunnelling to pull the lead to the other site is a reliable and safe alternative technique in cases of such difficulties. PP-350 FEMORAL VEIN GUIDANCE FOR PIPE-SHAPED CORONARY SINUS CANNULATION AND EPICARDIAL LEFT VENTRICULAR LEAD PLACEMENT FROM THE LEFT SUBCLAVIAN VEIN APPROACH U. Canpolat, H. Sunman, E.B. Kaya, L. Sahiner, ¸ K. Aytemir, A. Oto. Department of Cardiology, Hacettepe University, Ankara, Turkey Objective: Variations in coronary sinus (CS) anatomy can make subclavian vein approach difficult or even impossible for LV lead delivery. Combination of interventional and electrophysiological methods is therefore the state of art technique for implantation of LV leads. We describe practical method in which guidance of transfemoral route for pipe-shaped CS cannulation and epicardial placement of LV lead with superior approach. Methods: A 52-year-old diabetic male patient with non-ischemic dilated cardiomyopathy admitted to our hospital with the complaints of exertional dyspnea and limited functional capacity (New York Heart Association NYHA class III). He admitted to hospital several times between February 2009 and May 2011 for exacerbations of his heart failure symptoms despite optimal medical treatment. His transthoracic echocardiography showed LV ejection fraction of 15% with global severe hypokinesia and end-diastolic LV diameter was 72 mm. The 12-lead electrocardiogram demonstrated sinus rhythm with significant electrical dyssynchrony (QRS=160 msec). So, cardiac resynchronization therapy (CRT) implantation was attempted in our patient.
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subclavian route. A 100 cm deflectable decapolar electrophysiology catheter (EPxJ, Bard Electrophysiology Division, Lowell, MA, USA) was successfully positioned in the CS via transfemoral route. Then, diagnostic CS catheter (Marinr™, Medtronic, Mound View, MN, USA) was introduced into the CS by the help of transfemoral catheter. And LV lead was placed into the posterolateral branch of CS via subclavian vein approach. Pacing indices were satisfactory. The leads were connected to generator and the procedure was completed successfully. No complication occurred. Chest radiography and device interrogation 24 h postprocedure confirmed lead stability and correct functioning of the system. Conclusions: This practical approach to overcome pipe-shaped CS variations for LV lead placement may avoid the need for epicardial procedures when a subclavian approach fails. It remains to be determined whether it is a safer or more effective procedure. PP-351 CORONARY VENOUS ANGIOPLASTY TO A RING LIKE STRICTURE PREVENTING LEFT VENTRICULAR LEAD INSERTION: A CASE REPORT A. Deniz, M. Kanadası, ¸ M. Demir, A. Usal. Department of Cardiology, Cukurova ¸ University, Adana, Turkey Objective: Cardiac resynchronization therapy (CRT) is an alternative therapy in patients with severe systolic heart failure who have clues of dyssynchronous ventricular contraction and severe symptoms (NYHA III-IV) despite optimal medical therapy. The operators sometimes confront limitations to implant left ventricular lead in coronary veins. These include unsuitable branching angle of coronary veins and tortuosity of coronary sinus anatomy, postoperative deformation, presence of venous valves, absence of vessel in target location, and coronary venous stenosis. We here describe coronary venous angioplasty before left ventricular lead insertion in a patient with coronary venous stenosis. Methods: A 57-year-old male patient with drug refractory heart failure underwent biventricular pacemaker implantation. During the procedure, guiding catheter was engaged into the coronary sinus ositum, and coronary venography was taken to chose target coronary vein for left ventricular lead insertion. The lead could not be introduced into the coronary vein due to a stenosis caused by ring like stricture in the proximal portion of the vein (Figure 1).
Figure 1. Results: Under local anesthesia, the procedure was initiated with subclavian vein approach. The right ventricular lead was positioned at the apex and the right atrial lead in the atrial appendage. Exhaustive attempts at CS cannulation with a wide range of delivery systems, guidewires, and coronary catheters failed because of the pipe-shaped CS ostium which is a narrow pipe mouth pointing cranially before the remainder of the CS turns inferiorly at an angle and continues in the cranio-lateral direction. So, right femoral access was performed to guide CS cannulation via
Figure 1. A ring like stricture is seen at the ostium of the target vein. A coronary wire was advanced through the narrowing. The stenotic portion of the coronary vein was dilated with 2.5×10 mm angioplasty balloon with 9 atm pressure. Following dilatation, left ventricular lead was easily introduced into the posterior coronary vein without any complication. Duration of the
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Posters / International Journal of Cardiology 155S1 (2012) S129–S227
procedure was 50 minutes. Lenght of hospitalization was 3 days. Control echocardiography did not reveal any pericardial effusion. Pacemaker follow-up showed effective biventricular stimulation. Conclusions: There are some limitations preventing optimal lead implantation to target vein such as branching and tortusity of coronary veins, postoperative deformation, presence of venous valves, and venous stenosis. Although venous angioplasty is considered to be safe and effective method to overcome venous stenosis, serious complications may ensue such as rupture, perforation, dissection and thrombosis of the coronary vein. Therefore, close hemodynamic monitoring and control echocardiography should be done whenever coronary venous angioplasty is performed. PAH: An International Perspective PP-358 MAGNETIC RESONANCE IMAGING CONTRAST AGENT RELATED PULMONARY EDEMA: A CASE REPORT A. Demirhan1 , U.Y. Tekelioglu1 , A. Akkaya1 , E. Dagistan2 , S.S. Ayhan3 , S. Ozturk3 , I. Yıldız1 , H. Kocoglu1 . 1 Department of Anesthesiology and Reanimation, Abant Izzet Baysal University Medical School, Bolu, Turkey; 2 Department of Radiology, Abant Izzet Baysal University Medical School, Bolu, Turkey; 3 Department of Cardiology, Abant Izzet Baysal University Medical School, Bolu, Turkey Objective: This paper examines the case of a 37-year-old male patient reported to have developed noncardiogenic pulmonary edema after intravenous injection of gadobutrol during magnetic resonance imaging (MRI). Methods: Gadobutrol has a safety profile comparable to other Gadolinium-based MRI contrast agents (MRI-ca). The agent is often preferred as it provides superior quality MRI conditions. After intravenous (i.v.) administration, its plasma level rapidly peaks within minutes, and it is then excreted renally. It has extremely rare life-threatening systemic complications, which can lead to bronchospasm, hypersensitivity reactions and cardiovascular arrest.
showed an increase in pulmonary vascular density (Figure 1). Biochemical laboratory values were measured in the blood as follows: Ca: 6.9 mmol L−1 ; K: 2.4 mmol L−1 ; These results indicated potassium (10 mEq h−1 ) and calcium (1 mg kg−1 h−1 ) replacements. A day after admission, the patient was transferred to the cardiology service and observed for three days for complications. He was discharged without sequelae. Conclusions: Anaphylactic shock with noncardiogenic pulmonary edema after the use of gadobutrol is presented in this paper. As this is the first case in the literature, we suggest anaphylactic shock and noncardiogenic pulmonary edema must be kept in mind during MRI. Additionally, as in this case, accompanied hypopotassemia requires analysis and should be investigated in terms of gadobutrol attributable arrests, and, in particular, hERG mediated potassium current inhibition. PP-359 A CASE OF PULMONARY EMBOLI WITH SIGNIFICANT ALTERATION IN ELECTROCARDIOGRAM AFTER THROMBOLYSIS A. Kaya1 , M. Kurt2 , T. Isık ¸ 3 , H.I˙ . Tanboga1 , S. Topcu ¸ 4 , E. Aksakal4 . 1 Erzurum B¨ olge E˘gitim ve Arastırma ¸ Hastanesi, Ezrurum, Turkey; 2 ¨ Mustafa Kemal Universitesi Tıp Fak¨ ultesi, Hatay, Turkey; 3 Balıkesir ¨ ¨ Universitesi Tıp Fak¨ ultesi, Balıkesir, Turkey; 4 Atat¨ urk Universitesi Arastırma ¸ Hastanesi, Erzurum, Turkey Introduction: Pulmonary embolism (PE) is an emergent condition which may lead to life threatening right heart failure. Depending on the clinical status, its mortality rate may vary between 1 to60%. Patient and Methods: A 50 year old woman who was under treatment for femoropopliteal varicose veins had admitted to our emergency department with complaints of dyspnea and syncope which had started acutely after a long bus trip. Her blood pressure was 100/70 mmHg, pulse rate was 110/min and oxygen saturation was 90 % at arrival. Her electrocardiogram (ECG) showed sinus tachycardia with right bundle branch block (RBBB) (Figure 1a). Emergently performed echocardiogram showed that her pulmonary artery pressure was 50 mmHg with a mobile thrombus seen in right atrium (Figure 1b). In computerized tomography, thrombi were seen in both pulmonary arteries (Figure 1c). Intravenous heparin and alteplase (100 mg given in 2 hours) was given in the coronary care unit. After thrombolytic therapy, her dyspnea had resolved, hemodynamic parameters improved, pulmonary artery pressure dropped down to 15 mmHg and the RBBB had disappeared in the ECG (Figure 1d). Patient was discharged with oral warfarin therapy.
Figure 1. Chest X-Ray. (A) The image shows increased pulmonary vascularity; the X ray was obtained 30 min. after ICU admission. (B) The X ray after 12 hours of ICU admission. Results: A 37-year-old male patient with complaints of wrist pain was admitted to our neurology clinic. During the spinal MRI procedure, intravenous gadobutrol was given by cephalic vein (solution Gadovist, Bayer Schering Pharma AG, Germany) (14 ml). Following injection of the MRI-ca, the patient developed severe reactions, such as dyspnea, cyanosis, and loss of consciousness. Nasal oxygen was initiated. Methylprednisolone (i.v. 125 mg) was administered and the patient was transferred to the intensive care unit (ICU). He had no prior history of MRI-ca exposure, drug allergies, atopy, or systemic disease. He was unconscious on first examination in the ICU, and displayed bradypnea, excessive cyanosis, and absent arterial pulsation. PA chest radiography
Figure 1. (a) Electrocardiogram taken at arrival. (b) Echocardiogram showing right atrial thrombus. (c) Image of thrombi in pulmonary arteries. (d) Electrocardiogram taken after thrombolytic therapy.
Methods: After preparation and under sterile conditions, we were unable to engage the coronary sinus ostium from a puncture in the left subclavian vein. Atrial and ventricular leads were placed in the usual fashion from the left site (Figure 1A). We moved to the right site to get an access to the right subclavian vein and this time were able to place the coronary sinus lead in a lateral branch (Figure 1B). Then, a subcutaneous tunnel over the sternum was created to pull the coronary sinus lead to the left site adjacent to the other leads. The leads were connected to a CRT-D and were all implanted in a left infraclavicular surgical pocket (Figure 1A). No complications were encountered (Figure 1C). Conclusions: A difficulty with coronary sinus engagement sometimes occurs in CRT-(D) implantation. We demonstrate that gaining access in the contralateral site with subcutaneus, presternal tunnelling to pull the lead to the other site is a reliable and safe alternative technique in cases of such difficulties. PP-350 FEMORAL VEIN GUIDANCE FOR PIPE-SHAPED CORONARY SINUS CANNULATION AND EPICARDIAL LEFT VENTRICULAR LEAD PLACEMENT FROM THE LEFT SUBCLAVIAN VEIN APPROACH U. Canpolat, H. Sunman, E.B. Kaya, L. Sahiner, ¸ K. Aytemir, A. Oto. Department of Cardiology, Hacettepe University, Ankara, Turkey Objective: Variations in coronary sinus (CS) anatomy can make subclavian vein approach difficult or even impossible for LV lead delivery. Combination of interventional and electrophysiological methods is therefore the state of art technique for implantation of LV leads. We describe practical method in which guidance of transfemoral route for pipe-shaped CS cannulation and epicardial placement of LV lead with superior approach. Methods: A 52-year-old diabetic male patient with non-ischemic dilated cardiomyopathy admitted to our hospital with the complaints of exertional dyspnea and limited functional capacity (New York Heart Association NYHA class III). He admitted to hospital several times between February 2009 and May 2011 for exacerbations of his heart failure symptoms despite optimal medical treatment. His transthoracic echocardiography showed LV ejection fraction of 15% with global severe hypokinesia and end-diastolic LV diameter was 72 mm. The 12-lead electrocardiogram demonstrated sinus rhythm with significant electrical dyssynchrony (QRS=160 msec). So, cardiac resynchronization therapy (CRT) implantation was attempted in our patient.
S215
subclavian route. A 100 cm deflectable decapolar electrophysiology catheter (EPxJ, Bard Electrophysiology Division, Lowell, MA, USA) was successfully positioned in the CS via transfemoral route. Then, diagnostic CS catheter (Marinr™, Medtronic, Mound View, MN, USA) was introduced into the CS by the help of transfemoral catheter. And LV lead was placed into the posterolateral branch of CS via subclavian vein approach. Pacing indices were satisfactory. The leads were connected to generator and the procedure was completed successfully. No complication occurred. Chest radiography and device interrogation 24 h postprocedure confirmed lead stability and correct functioning of the system. Conclusions: This practical approach to overcome pipe-shaped CS variations for LV lead placement may avoid the need for epicardial procedures when a subclavian approach fails. It remains to be determined whether it is a safer or more effective procedure. PP-351 CORONARY VENOUS ANGIOPLASTY TO A RING LIKE STRICTURE PREVENTING LEFT VENTRICULAR LEAD INSERTION: A CASE REPORT A. Deniz, M. Kanadası, ¸ M. Demir, A. Usal. Department of Cardiology, Cukurova ¸ University, Adana, Turkey Objective: Cardiac resynchronization therapy (CRT) is an alternative therapy in patients with severe systolic heart failure who have clues of dyssynchronous ventricular contraction and severe symptoms (NYHA III-IV) despite optimal medical therapy. The operators sometimes confront limitations to implant left ventricular lead in coronary veins. These include unsuitable branching angle of coronary veins and tortuosity of coronary sinus anatomy, postoperative deformation, presence of venous valves, absence of vessel in target location, and coronary venous stenosis. We here describe coronary venous angioplasty before left ventricular lead insertion in a patient with coronary venous stenosis. Methods: A 57-year-old male patient with drug refractory heart failure underwent biventricular pacemaker implantation. During the procedure, guiding catheter was engaged into the coronary sinus ositum, and coronary venography was taken to chose target coronary vein for left ventricular lead insertion. The lead could not be introduced into the coronary vein due to a stenosis caused by ring like stricture in the proximal portion of the vein (Figure 1).
Figure 1. Results: Under local anesthesia, the procedure was initiated with subclavian vein approach. The right ventricular lead was positioned at the apex and the right atrial lead in the atrial appendage. Exhaustive attempts at CS cannulation with a wide range of delivery systems, guidewires, and coronary catheters failed because of the pipe-shaped CS ostium which is a narrow pipe mouth pointing cranially before the remainder of the CS turns inferiorly at an angle and continues in the cranio-lateral direction. So, right femoral access was performed to guide CS cannulation via
Figure 1. A ring like stricture is seen at the ostium of the target vein. A coronary wire was advanced through the narrowing. The stenotic portion of the coronary vein was dilated with 2.5×10 mm angioplasty balloon with 9 atm pressure. Following dilatation, left ventricular lead was easily introduced into the posterior coronary vein without any complication. Duration of the
S216
Posters / International Journal of Cardiology 155S1 (2012) S129–S227
procedure was 50 minutes. Lenght of hospitalization was 3 days. Control echocardiography did not reveal any pericardial effusion. Pacemaker follow-up showed effective biventricular stimulation. Conclusions: There are some limitations preventing optimal lead implantation to target vein such as branching and tortusity of coronary veins, postoperative deformation, presence of venous valves, and venous stenosis. Although venous angioplasty is considered to be safe and effective method to overcome venous stenosis, serious complications may ensue such as rupture, perforation, dissection and thrombosis of the coronary vein. Therefore, close hemodynamic monitoring and control echocardiography should be done whenever coronary venous angioplasty is performed. PAH: An International Perspective PP-358 MAGNETIC RESONANCE IMAGING CONTRAST AGENT RELATED PULMONARY EDEMA: A CASE REPORT A. Demirhan1 , U.Y. Tekelioglu1 , A. Akkaya1 , E. Dagistan2 , S.S. Ayhan3 , S. Ozturk3 , I. Yıldız1 , H. Kocoglu1 . 1 Department of Anesthesiology and Reanimation, Abant Izzet Baysal University Medical School, Bolu, Turkey; 2 Department of Radiology, Abant Izzet Baysal University Medical School, Bolu, Turkey; 3 Department of Cardiology, Abant Izzet Baysal University Medical School, Bolu, Turkey Objective: This paper examines the case of a 37-year-old male patient reported to have developed noncardiogenic pulmonary edema after intravenous injection of gadobutrol during magnetic resonance imaging (MRI). Methods: Gadobutrol has a safety profile comparable to other Gadolinium-based MRI contrast agents (MRI-ca). The agent is often preferred as it provides superior quality MRI conditions. After intravenous (i.v.) administration, its plasma level rapidly peaks within minutes, and it is then excreted renally. It has extremely rare life-threatening systemic complications, which can lead to bronchospasm, hypersensitivity reactions and cardiovascular arrest.
showed an increase in pulmonary vascular density (Figure 1). Biochemical laboratory values were measured in the blood as follows: Ca: 6.9 mmol L−1 ; K: 2.4 mmol L−1 ; These results indicated potassium (10 mEq h−1 ) and calcium (1 mg kg−1 h−1 ) replacements. A day after admission, the patient was transferred to the cardiology service and observed for three days for complications. He was discharged without sequelae. Conclusions: Anaphylactic shock with noncardiogenic pulmonary edema after the use of gadobutrol is presented in this paper. As this is the first case in the literature, we suggest anaphylactic shock and noncardiogenic pulmonary edema must be kept in mind during MRI. Additionally, as in this case, accompanied hypopotassemia requires analysis and should be investigated in terms of gadobutrol attributable arrests, and, in particular, hERG mediated potassium current inhibition. PP-359 A CASE OF PULMONARY EMBOLI WITH SIGNIFICANT ALTERATION IN ELECTROCARDIOGRAM AFTER THROMBOLYSIS A. Kaya1 , M. Kurt2 , T. Isık ¸ 3 , H.I˙ . Tanboga1 , S. Topcu ¸ 4 , E. Aksakal4 . 1 Erzurum B¨ olge E˘gitim ve Arastırma ¸ Hastanesi, Ezrurum, Turkey; 2 ¨ Mustafa Kemal Universitesi Tıp Fak¨ ultesi, Hatay, Turkey; 3 Balıkesir ¨ ¨ Universitesi Tıp Fak¨ ultesi, Balıkesir, Turkey; 4 Atat¨ urk Universitesi Arastırma ¸ Hastanesi, Erzurum, Turkey Introduction: Pulmonary embolism (PE) is an emergent condition which may lead to life threatening right heart failure. Depending on the clinical status, its mortality rate may vary between 1 to60%. Patient and Methods: A 50 year old woman who was under treatment for femoropopliteal varicose veins had admitted to our emergency department with complaints of dyspnea and syncope which had started acutely after a long bus trip. Her blood pressure was 100/70 mmHg, pulse rate was 110/min and oxygen saturation was 90 % at arrival. Her electrocardiogram (ECG) showed sinus tachycardia with right bundle branch block (RBBB) (Figure 1a). Emergently performed echocardiogram showed that her pulmonary artery pressure was 50 mmHg with a mobile thrombus seen in right atrium (Figure 1b). In computerized tomography, thrombi were seen in both pulmonary arteries (Figure 1c). Intravenous heparin and alteplase (100 mg given in 2 hours) was given in the coronary care unit. After thrombolytic therapy, her dyspnea had resolved, hemodynamic parameters improved, pulmonary artery pressure dropped down to 15 mmHg and the RBBB had disappeared in the ECG (Figure 1d). Patient was discharged with oral warfarin therapy.
Figure 1. Chest X-Ray. (A) The image shows increased pulmonary vascularity; the X ray was obtained 30 min. after ICU admission. (B) The X ray after 12 hours of ICU admission. Results: A 37-year-old male patient with complaints of wrist pain was admitted to our neurology clinic. During the spinal MRI procedure, intravenous gadobutrol was given by cephalic vein (solution Gadovist, Bayer Schering Pharma AG, Germany) (14 ml). Following injection of the MRI-ca, the patient developed severe reactions, such as dyspnea, cyanosis, and loss of consciousness. Nasal oxygen was initiated. Methylprednisolone (i.v. 125 mg) was administered and the patient was transferred to the intensive care unit (ICU). He had no prior history of MRI-ca exposure, drug allergies, atopy, or systemic disease. He was unconscious on first examination in the ICU, and displayed bradypnea, excessive cyanosis, and absent arterial pulsation. PA chest radiography
Figure 1. (a) Electrocardiogram taken at arrival. (b) Echocardiogram showing right atrial thrombus. (c) Image of thrombi in pulmonary arteries. (d) Electrocardiogram taken after thrombolytic therapy.