- Email: [email protected]
Right superior vena cava drainage into the left atrium revealed by multiples strokes after pacemaker implantation
IMAGE
Right superior vena cava drainage into the left atrium revealed by multiples strokes after pacemaker implantation Pierre-Yves Courand, MD, MSc,* Nicolas Girerd, MD, MSc,* Samuel Chauveau, MD,* Philippe Chevalier, MD, PhD*† From the *Department of Rhythmology, Hospices Civils de Lyon, Louis Pradel Cardiovascular Hospital, Lyon, France, and †Lyon Reference Center for inherited Arrhythmias, Hospices Civils de Lyon, Louis Pradel Cardiovascular Hospital, Lyon, France.
Figure 1
KEYWORDS Pacemaker; Stroke; Congenital heart disease; Right superior vena cava; Left atrium ABBREVIATIONS CS ⫽ coronary sinus; CT ⫽ computed tomography; LA ⫽ left atrium; LSVC ⫽ left superior vena cava; RPV ⫽ right superior
pulmonary vein; RSVC ⫽ right superior vena cava (Heart Rhythm 2013; 10:1735–1736) Address reprint requests and correspondence: Dr. Philippe Chevalier, Service de Rythmologie, Hôpital cardiologique Louis Pradel, 59 bd Pinel, 69677 BRON Cedex, France. E-mail address: [email protected].
1547-5271/$ -see front matter © 2013 Heart Rhythm Society. All rights reserved.
http://dx.doi.org/10.1016/j.hrthm.2012.07.029
1736 An 84-year-old woman had undergone dual-chamber pacemaker implantation in a primary care hospital for sick sinus syndrome. The leads were inserted through the right subclavian vein because the patient was left-handed. One year later, she suffered from an ischemic stroke. During ventricular pacing, ECG showed a right bundle branch block pattern, and chest radiography (Figure 1A) suggested that pacing lead tips were in the left atrium (LA) and left ventricle. After transthoracic and transesophageal echocardiography, it was initially thought that the leads passed through a patent foramen ovale. A thrombus on the ventricular lead was identified. Cardiac surgery was ruled out because of the high risk of periprocedural stroke. Vitamin K antagonist was the only medication prescribed. One year later, she presented to our institution after a recurrent ischemic stroke. Transthoracic echocardiography showed a dilated coronary sinus (CS). The patient underwent contrast-enhanced computed tomography (CT), which demonstrated right superior vena cava (RSVC) drainage into the LA through the right superior pulmonary vein (RPV) and a persistent left superior vena cava (LSVC) drainage in the right atrium through the CS (Figure 1B). A video-assisted right-sided mini-thoracotomy with cardiopulmonary bypass was used to perform a left atriotomy. The presence of a thrombus surrounding the leads in the left cardiac cavities was confirmed. The leads were carefully removed, ensuring that the clot was not dislodged. Because the patient was very rarely paced, pacemaker reimplantation was not planned. Two years after surgery, the patient developed complete atrioventricular block. A single-chamber pacemaker was
Heart Rhythm, Vol 10, No 11, November 2013 implanted through the left subclavian vein. The leads were guided to the right ventricle via the LSVC and the CS (Figure 1C). Only 20 cases of RSVC drainage into the LA have been previously reported. Most often, this cardiac malformation is suspected in children presenting with cyanosis or chronic hypoxemia due to a right-to-left shunt.1 The association of RSVC drainage into the LA and LSVC drainage into the right atrium has been reported only twice.2,3 Importantly, in these 2 reports, the LSVC drained directly into the right atrium (ie, not through the CS). To the best of our knowledge, we report the first case of RSVC drainage in the LA associated with LSVC drainage in the CS. This report reinforces the need to rule out malpositioned pacemaker leads in case of recurrent ischemic strokes in a pacemaker patient. In this setting, a CT scan is the best tool for precise documentation of both the location of the leads and the cardiovascular anatomy.4 It also should be kept in mind that rare cardiac malformations do exist in previously asymptomatic aged adults and can be associated with severe complications when intravascular devices are implanted.
References 1. 2.
3.
4.
Levy SE, Blalock A. Fractionation of the output of the heart and the oxygen consumption of normal unanesthetized dogs. Am J Physiol 1937;118:368 –371. Leys D, Manouvrier J, Dupard T, et al. Right superior vena cava draining into the left atrium with left superior vena cava draining into the right atrium. Br Med J 1986;293:855. Pretorius PM, Gleeson FV. Case 74: right-sided superior vena cava draining into left atrium in a patient with persistent left-sided superior vena cava. Radiology 2004;232:730 –734. Sivapathasuntharam D, Hyde JA, Reay V, Rajkumar C. Recurrent strokes caused by a malpositioned pacemaker lead. Age Ageing 2012;41:420 – 421.
Right superior vena cava drainage into the left atrium revealed by multiples strokes after pacemaker implantation Pierre-Yves Courand, MD, MSc,* Nicolas Girerd, MD, MSc,* Samuel Chauveau, MD,* Philippe Chevalier, MD, PhD*† From the *Department of Rhythmology, Hospices Civils de Lyon, Louis Pradel Cardiovascular Hospital, Lyon, France, and †Lyon Reference Center for inherited Arrhythmias, Hospices Civils de Lyon, Louis Pradel Cardiovascular Hospital, Lyon, France.
Figure 1
KEYWORDS Pacemaker; Stroke; Congenital heart disease; Right superior vena cava; Left atrium ABBREVIATIONS CS ⫽ coronary sinus; CT ⫽ computed tomography; LA ⫽ left atrium; LSVC ⫽ left superior vena cava; RPV ⫽ right superior
pulmonary vein; RSVC ⫽ right superior vena cava (Heart Rhythm 2013; 10:1735–1736) Address reprint requests and correspondence: Dr. Philippe Chevalier, Service de Rythmologie, Hôpital cardiologique Louis Pradel, 59 bd Pinel, 69677 BRON Cedex, France. E-mail address: [email protected].
1547-5271/$ -see front matter © 2013 Heart Rhythm Society. All rights reserved.
http://dx.doi.org/10.1016/j.hrthm.2012.07.029
1736 An 84-year-old woman had undergone dual-chamber pacemaker implantation in a primary care hospital for sick sinus syndrome. The leads were inserted through the right subclavian vein because the patient was left-handed. One year later, she suffered from an ischemic stroke. During ventricular pacing, ECG showed a right bundle branch block pattern, and chest radiography (Figure 1A) suggested that pacing lead tips were in the left atrium (LA) and left ventricle. After transthoracic and transesophageal echocardiography, it was initially thought that the leads passed through a patent foramen ovale. A thrombus on the ventricular lead was identified. Cardiac surgery was ruled out because of the high risk of periprocedural stroke. Vitamin K antagonist was the only medication prescribed. One year later, she presented to our institution after a recurrent ischemic stroke. Transthoracic echocardiography showed a dilated coronary sinus (CS). The patient underwent contrast-enhanced computed tomography (CT), which demonstrated right superior vena cava (RSVC) drainage into the LA through the right superior pulmonary vein (RPV) and a persistent left superior vena cava (LSVC) drainage in the right atrium through the CS (Figure 1B). A video-assisted right-sided mini-thoracotomy with cardiopulmonary bypass was used to perform a left atriotomy. The presence of a thrombus surrounding the leads in the left cardiac cavities was confirmed. The leads were carefully removed, ensuring that the clot was not dislodged. Because the patient was very rarely paced, pacemaker reimplantation was not planned. Two years after surgery, the patient developed complete atrioventricular block. A single-chamber pacemaker was
Heart Rhythm, Vol 10, No 11, November 2013 implanted through the left subclavian vein. The leads were guided to the right ventricle via the LSVC and the CS (Figure 1C). Only 20 cases of RSVC drainage into the LA have been previously reported. Most often, this cardiac malformation is suspected in children presenting with cyanosis or chronic hypoxemia due to a right-to-left shunt.1 The association of RSVC drainage into the LA and LSVC drainage into the right atrium has been reported only twice.2,3 Importantly, in these 2 reports, the LSVC drained directly into the right atrium (ie, not through the CS). To the best of our knowledge, we report the first case of RSVC drainage in the LA associated with LSVC drainage in the CS. This report reinforces the need to rule out malpositioned pacemaker leads in case of recurrent ischemic strokes in a pacemaker patient. In this setting, a CT scan is the best tool for precise documentation of both the location of the leads and the cardiovascular anatomy.4 It also should be kept in mind that rare cardiac malformations do exist in previously asymptomatic aged adults and can be associated with severe complications when intravascular devices are implanted.
References 1. 2.
3.
4.
Levy SE, Blalock A. Fractionation of the output of the heart and the oxygen consumption of normal unanesthetized dogs. Am J Physiol 1937;118:368 –371. Leys D, Manouvrier J, Dupard T, et al. Right superior vena cava draining into the left atrium with left superior vena cava draining into the right atrium. Br Med J 1986;293:855. Pretorius PM, Gleeson FV. Case 74: right-sided superior vena cava draining into left atrium in a patient with persistent left-sided superior vena cava. Radiology 2004;232:730 –734. Sivapathasuntharam D, Hyde JA, Reay V, Rajkumar C. Recurrent strokes caused by a malpositioned pacemaker lead. Age Ageing 2012;41:420 – 421.