- Email: [email protected]
Reply to the Editor—Out of Service Lead
e68
Heart Rhythm, Vol 10, No 5, May 2013
period when patients with TTS tend to have a transient ECG improvement with partial reversal of negative T waves. Finally, with regard to ECG changes in atypical TTS variants, the discrepancy between distribution of T-wave inversion and left ventricular contractile dysfunction pattern can be explained by the noncomplete overlap between regional wall akinesia/dyskinesia and ME. It is noteworthy that the few cases of atypical TTS reported in the literature with the detailed description of ECG repolarization changes and ME on cardiac magnetic resonance showed a good concordance between the ECG location of T-wave inversion and LV regional distribution of signal hyperintensity on T2weighted sequences for ME.6–8 This finding that the association of T-wave inversion/QT interval prolongation with ME is also demonstrable in atypical variants further supports the emerging concept of a cause-effect relationship between transient ME and ECG repolarization changes in TTS. Martina Perazzolo Marra, MD, PhD Alessandro Zorzi A, MD Domenico Corrado, MD, PhD [email protected] Department of Cardiac, Thoracic and Vascular Sciences University of Padova, Padova, Italy
References 1. Perazzolo Marra M, Zorzi A, Corbetti F, et al. Apicobasal gradient of left ventricular myocardial edema underlies transient T-wave inversion and QT interval prolongation (Wellens’ ECG pattern) in Tako-Tsubo cardiomyopathy. Heart Rhythm 2013;10:70–77. 2. De Zwaan C, B¨ar WHM, Wellens HJJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in the left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982;103:730–736. 3. Rhinehardt J, Brady WJ, Perron AD, et al. Electrocardiographic manifestations of Wellens’ syndrome. Am J Emerg Med 2002;20:638–643. 4. Bucciarelli-Ducci C, Denes P, Holly TA, Wu E. Pseudo Wellens T-waves in patients with suspected myocardial infarction: how cardiac magnetic resonance imaging can help the diagnosis Int J Cardiol 2008;128:e68–e71. 5. Migliore F, Zorzi A, Marra MP, et al. Myocardial edema underlies dynamic T-wave inversion (Wellens’ ECG pattern) in patients with reversible left ventricular dysfunction. Heart Rhythm 2011;8:1629–1634. 6. Gerbaud E, Jaussaud J, Lederlin M, Re´ant P. Transient left ventricular non-apical balooning syndrome: diagnosis with multiple imaging modalities. Arch Cardiovasc Dis 2010;103:270–272. 7. Daly MJ, Harbinson MT, Dixon LJ, Spence MS. An unusual case of midventricular Takotsubo cardiomyopathy. Q J Med 2010;103:695–696. 8. Zorzi A, Perazzolo MM, Migliore F, et al. Relationship between repolarization abnormalities and myocardial edema in atypical Tako-Tsubo syndrome. J. Electrocardiol. 2013; (in press).
To the Editor—Out-of-service lead I appreciated the case study by Hansen et al1 and compliment the authors on their analysis of this case. A similar but not absolutely identical phenomenon has been reported.2 It involved an insulation abrasion involving the intra-atrial portion of the ventricular lead occurring approximately
12-month postimplant and presumably caused by the other lead in proximity to the first. The case was that of a young patient with complete heart block who underwent uncomplicated implantation of a dual-chamber dual-unipolar pacing system. Approximately 12-month postimplant, she presented with intermittent ventricular oversensing of atrial depolarizations and right phrenic nerve stimulation. Eventual management was that of ventricular lead replacement. Fyke3 described the case of side-by-side insulation failure associated with rib-clavicle crush, which would allow for a multiplicity of manifestations including oversensing of events from the opposite chamber as well as crossstimulation due to crossover between the 2 leads. The authors do not comment on the stimulation impedances, but the stimulation impedance of the abandoned lead could not be measured and the impedance change associated with an external abrasion of a bipolar lead will usually be within the normal day-to-day measurement variation, as all that the abrasion will do is increase the surface area of the virtual proximal electrode of the abraded lead. The point of contact would also have had to be someplace beyond the fracture involving the abandoned chronic unipolar lead; this was probably intravascular, making it difficult, if not impossible, to locate much less repair even if the patient was subjected to an operative intervention. The authors’ use of the 12-lead electrocardiogram is also to be complimented. While the changes between ventricular depolarization in association with the ventricular output and the atrial output were subtle, I believe that was the key to the final analysis.4 Side-by-side abrasions of 2 leads can result in unusual manifestations, the cause of which will usually not be appreciated without a meticulous and detailed analysis. Paul A. Levine, MD, FHRS, CCDS [email protected] Loma Linda University School of Medicine Stevenson Ranch, California
References 1. Hansen JC, Moss JD, Nayak HN, Beshai JF. Out of service lead: abnormal presentation at follow-up. Heart Rhythm 2013;10:144–146. 2. Levine PA. Clinical manifestations of lead insulation defects. J Electrophysiol 1987;1:144–155. 3. Fyke FE III. Simultaneous insulation deterioration associated with side-by-side subclavian placement of two polyurethane leads. Pacing Clin Electrophysiol 1988;11:1571–1574. 4. Barold SS, Levine PA, Ovsyshcher IE. The paced 12-lead electrocardiogram should no longer be neglected in pacemaker follow-up. Pacing Clin Electrophysiol 2001;24:1455–1458.
Reply to the Editor—Out-of-service lead We are appreciative of Dr Levine’s comments and interest in our case report. We agree that there are several case reports
Letters to the Editor in the literature describing lead-lead interactions resulting in insulation abrasions and failures that manifest as oversensing of opposite chamber and cross-stimulation. However, these reports address leads that were “in-service” and quite different from our report of an “out-of-service” abandoned lead resulting in pacing. We could not agree more with Dr Levine regarding the 12-lead electrocardiogram as the key to the final analysis and
e69 that indeed the paced 12-lead electrocardiogram should not be neglected in pacemaker follow-up. John F. Beshai, MD, FHRS [email protected] Department of Medicine, Section of EP, University of Chicago Hospitals, Chicago, Illinois
Heart Rhythm, Vol 10, No 5, May 2013
period when patients with TTS tend to have a transient ECG improvement with partial reversal of negative T waves. Finally, with regard to ECG changes in atypical TTS variants, the discrepancy between distribution of T-wave inversion and left ventricular contractile dysfunction pattern can be explained by the noncomplete overlap between regional wall akinesia/dyskinesia and ME. It is noteworthy that the few cases of atypical TTS reported in the literature with the detailed description of ECG repolarization changes and ME on cardiac magnetic resonance showed a good concordance between the ECG location of T-wave inversion and LV regional distribution of signal hyperintensity on T2weighted sequences for ME.6–8 This finding that the association of T-wave inversion/QT interval prolongation with ME is also demonstrable in atypical variants further supports the emerging concept of a cause-effect relationship between transient ME and ECG repolarization changes in TTS. Martina Perazzolo Marra, MD, PhD Alessandro Zorzi A, MD Domenico Corrado, MD, PhD [email protected] Department of Cardiac, Thoracic and Vascular Sciences University of Padova, Padova, Italy
References 1. Perazzolo Marra M, Zorzi A, Corbetti F, et al. Apicobasal gradient of left ventricular myocardial edema underlies transient T-wave inversion and QT interval prolongation (Wellens’ ECG pattern) in Tako-Tsubo cardiomyopathy. Heart Rhythm 2013;10:70–77. 2. De Zwaan C, B¨ar WHM, Wellens HJJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in the left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982;103:730–736. 3. Rhinehardt J, Brady WJ, Perron AD, et al. Electrocardiographic manifestations of Wellens’ syndrome. Am J Emerg Med 2002;20:638–643. 4. Bucciarelli-Ducci C, Denes P, Holly TA, Wu E. Pseudo Wellens T-waves in patients with suspected myocardial infarction: how cardiac magnetic resonance imaging can help the diagnosis Int J Cardiol 2008;128:e68–e71. 5. Migliore F, Zorzi A, Marra MP, et al. Myocardial edema underlies dynamic T-wave inversion (Wellens’ ECG pattern) in patients with reversible left ventricular dysfunction. Heart Rhythm 2011;8:1629–1634. 6. Gerbaud E, Jaussaud J, Lederlin M, Re´ant P. Transient left ventricular non-apical balooning syndrome: diagnosis with multiple imaging modalities. Arch Cardiovasc Dis 2010;103:270–272. 7. Daly MJ, Harbinson MT, Dixon LJ, Spence MS. An unusual case of midventricular Takotsubo cardiomyopathy. Q J Med 2010;103:695–696. 8. Zorzi A, Perazzolo MM, Migliore F, et al. Relationship between repolarization abnormalities and myocardial edema in atypical Tako-Tsubo syndrome. J. Electrocardiol. 2013; (in press).
To the Editor—Out-of-service lead I appreciated the case study by Hansen et al1 and compliment the authors on their analysis of this case. A similar but not absolutely identical phenomenon has been reported.2 It involved an insulation abrasion involving the intra-atrial portion of the ventricular lead occurring approximately
12-month postimplant and presumably caused by the other lead in proximity to the first. The case was that of a young patient with complete heart block who underwent uncomplicated implantation of a dual-chamber dual-unipolar pacing system. Approximately 12-month postimplant, she presented with intermittent ventricular oversensing of atrial depolarizations and right phrenic nerve stimulation. Eventual management was that of ventricular lead replacement. Fyke3 described the case of side-by-side insulation failure associated with rib-clavicle crush, which would allow for a multiplicity of manifestations including oversensing of events from the opposite chamber as well as crossstimulation due to crossover between the 2 leads. The authors do not comment on the stimulation impedances, but the stimulation impedance of the abandoned lead could not be measured and the impedance change associated with an external abrasion of a bipolar lead will usually be within the normal day-to-day measurement variation, as all that the abrasion will do is increase the surface area of the virtual proximal electrode of the abraded lead. The point of contact would also have had to be someplace beyond the fracture involving the abandoned chronic unipolar lead; this was probably intravascular, making it difficult, if not impossible, to locate much less repair even if the patient was subjected to an operative intervention. The authors’ use of the 12-lead electrocardiogram is also to be complimented. While the changes between ventricular depolarization in association with the ventricular output and the atrial output were subtle, I believe that was the key to the final analysis.4 Side-by-side abrasions of 2 leads can result in unusual manifestations, the cause of which will usually not be appreciated without a meticulous and detailed analysis. Paul A. Levine, MD, FHRS, CCDS [email protected] Loma Linda University School of Medicine Stevenson Ranch, California
References 1. Hansen JC, Moss JD, Nayak HN, Beshai JF. Out of service lead: abnormal presentation at follow-up. Heart Rhythm 2013;10:144–146. 2. Levine PA. Clinical manifestations of lead insulation defects. J Electrophysiol 1987;1:144–155. 3. Fyke FE III. Simultaneous insulation deterioration associated with side-by-side subclavian placement of two polyurethane leads. Pacing Clin Electrophysiol 1988;11:1571–1574. 4. Barold SS, Levine PA, Ovsyshcher IE. The paced 12-lead electrocardiogram should no longer be neglected in pacemaker follow-up. Pacing Clin Electrophysiol 2001;24:1455–1458.
Reply to the Editor—Out-of-service lead We are appreciative of Dr Levine’s comments and interest in our case report. We agree that there are several case reports
Letters to the Editor in the literature describing lead-lead interactions resulting in insulation abrasions and failures that manifest as oversensing of opposite chamber and cross-stimulation. However, these reports address leads that were “in-service” and quite different from our report of an “out-of-service” abandoned lead resulting in pacing. We could not agree more with Dr Levine regarding the 12-lead electrocardiogram as the key to the final analysis and
e69 that indeed the paced 12-lead electrocardiogram should not be neglected in pacemaker follow-up. John F. Beshai, MD, FHRS [email protected] Department of Medicine, Section of EP, University of Chicago Hospitals, Chicago, Illinois