Ann Thorac Surg 2005;80:328-330
© 2005 The Society of Thoracic Surgeons
Case report
Left Ventricular Pacing Through the Anterior Interventricular Vein in a Patient With Mechanical Tricuspid, Aortic and Mitral Valves
Masataka Yoda, MD*,
Bert Hansky, MD,
Sebastian Schulte-Eistrup, MD,
Reiner Koerfer, MD, PhD,
Kazutomo Minami, MD, PhD
Department of Thoracic and Cardiovascular Surgery, Heart Center North Rhine-Westphalia, University of Bochum, Bad Oeynhausen, Germany
Accepted for publication January 9, 2004.
* Address reprint requests to Dr Yoda, Department of Thoracic and Cardiovascular Surgery, Heart Center North Rhine-Westphalia, University of Bochum, Georgstrasse 11, 32545 Bad Oeynhausen, Germany (Email: masatakayoda{at}aol.com).
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Abstract
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Transvenous endocardial pacemaker implantation is contraindicated in patients after mechanical tricuspid valve replacement. A 76-year-old woman who suffered from bradyarrhythmia was implanted with a left ventricular pacing lead through a transvenous coronary vein after aortic, mitral, and tricuspid valve replacements. There were no complications and the stimulation thresholds were stable. The use of coronary vein leads provides a minimally invasive approach, safety, and effective stimulation for patients with a mechanical tricuspid valve.
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Introduction
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Transvenous endocardial pacemaker implantation is contraindicated for patients after mechanical tricuspid valve replacement. These patients usually undergo epicardial implantation through an anterolateral thoracotomy or sternotomy, which has been associated with frequent increasing thresholds and limited lead survival. We present a case of successful left ventricular (LV) pacing through the anterior interventricular vein after previous mechanical tricuspid, aortic and mitral valve replacements.
A 76-year-old woman was admitted for an operation for tricuspid regurgitation (grade IV/IV). Chronic atrial fibrillation had been documented for 5 years. Previous valve procedures were a closed digital mitral commissurotomy in 1974, and in 1999 aortic and mitral valve replacements with mechanical valves (St. Jude Medical, St. Paul, MNA), as well as tricuspid valve repair using the De-Vega method. Four years later, the tricuspid valve had to be replaced because of recurrent grade IV tricuspid valve regurgitation. In the postoperative course, the patient had ventricular bradycardia (heart rate <30 bpm) and slow atrial fibrillation that required permanent pacing.
To avoid a third thoracotomy, we implanted a LV pacing lead by way of a coronary vein. After accessing the left subclavian vein, a guiding catheter (Attain 6218A-AM’38, Medtronic Inc., Minneapolis, MN) was introduced and placed into the ostium of the coronary sinus. Then, a venogram of the coronary veins was performed and the anatomy of the anterior interventricular vein established (Fig 1).
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Fig 1. Coronary sinus venogram in the left anterior oblique view showing the anterior interventricular vein (AIV).
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The unipolar steroid-eluting endocardial pacing lead (Attain 4193 OTW’38, Medtronic Inc, Minneapolis, MN) was implanted into the anterior interventricular vein according to the "over-the-wire" technique, using a guidewire (Balance Middle Weight, Hi-Torque Guide Wire’38, Guidant, St. Paul, MN) (Fig 2). Measurements at implantation: threshold was 2.3 V at 0.5 ms; R wave was 8.0 mV, impedance was 750 
at 5.0 V. The electrocardiogram showed LV pacing with right bundle branch block configuration and left anterior hemiblock. The lead was secured and connected to a single-chamber rate-adaptive pacemaker (Kappa SR’38, Medtronic Inc, Minneapolis, MN) that was placed in a subfascial prepectoral pocket and programed to ventricular demand rate-responsive at 80 to 90 ppm. Three days after the implantation, a roentgenogram showed no lead dislodgement. After a week, we checked the pacemaker. It showed low threshold (2.0 V, 0.5 ms), good R-wave sensing (10 mV), and stable impedance (800 5.0 V).
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Fig 2. Coronary sinus venogram in the left anterior oblique view showing the ventricular pacing lead in the anterior interventricular vein (AIV).
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Comment
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Transvenous placement of a right ventricular pacemaker lead offers stable long-term pacing with low stimulation thresholds. However, in patients with tricuspid protheses, transvenous right ventricular endocardial pacing is contraindicated. In these cases, epicardial pacing through an anterolateral thoracotomy or sternotomy is often used. Epicardial pacing lead implantation has been associated with the frequent development of high stimulation thresholds and limited lead survival. Moreover, anterolateral thoracotomy and sternotomy approaches are invasive operations that require total anesthesia and surgical incision. They carry risks of bleeding, ventricular injury, and wound infection.
Daoud and colleagues [1] showed that the thoracotomy approach for biventricular pacing lead implantation led to significantly higher exacerbation of congestive heart failure, longer hospital stays, and lower survival rates than the transvenous approach. Success rates for the pacing lead implantation were 100% with the thoracotomy approach and 90% with the transvenous approach, but there was no significant difference.
Recently, some authors have reported epicardial LV pacing lead placement by using a robotic assistant [2]. However, this had several disadvantages, such as requiring total anesthesia, single-lung ventilation, and sterile operating room. Patients who have thorax adherence as a result of left thorax or lung operations, radiotherapy, pneumonia, or severe heart failure, cannot be approached through the left thorax. Furthermore, single-lung ventilation is contraindicated in patients who have severe respiratory disease or severe heart failure. DeRose and colleagues [2] reported that single-lung ventilation caused pneumonia, and that ventricular injury occurred during robotic pacing lead placement.
On the other hand, the transvenous approach requires no surgical invasion, no single-lung ventilation and no contact with the lung.
Bai and colleagues [3] first reported the use of LV pacing after prosthetic tricuspid valve replacement. They encountered a high pacing threshold in the middle cardiac vein and had to place the lead in the great cardiac vein. The most common complications of LV pacing through a coronary vein are diaphragmatic stimulation, coronary sinus dissection, and lead dislodgement [4]. The development of leads specifically designed for left ventricular stimulation by way of the coronary sinus may solve the problem of lead dislodgement.
Hansky and colleagues [5] showed good results for LV pacing in patients with mechanical tricuspid valves. During the follow-up period (3 to 18 months, mean 9 months), all patients were functioning without complications and the stimulation thresholds were stable (<2.0V).
The use of LV pacing through coronary vein leads in patients with mechanical tricuspid valves provides a minimally invasive approach and effective stimulation of the ventricle. LV pacing with these leads should be the first choice for patients with mechanical tricuspid valves who require permanent ventricular pacing.
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References
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- Daoud EG, Kalbfleisch SJ, Hummel JD, et al. Implantation techniques and chronic lead parameters of biventricular pacing dual-chamber defibrillators J Cardiovasc Electrophysiol 2002;13:964-970.[Medline]
- DeRose JJ, Ashton RC, Belsley S, et al. Robotically assisted left ventricular epicardial lead implantation for biventricular pacing J Am Coll Cardiol 2003;41:1414-1419.[Abstract/Free Full Text]
- Bai Y, Strathmore N, Mond H, Grigg L, Hunt D. Permanent ventricular pacing via the great cardiac vein PACE 1994;17:678-683.
- Alonso C, Leclercq C, d’Allonnes FR, et al. Six year experience of transvenous left ventricular lead implantation for permanent biventricular pacing in patients with advanced heart failuretechnical aspects. Heart 2001;86:405-410.[Abstract/Free Full Text]
- Hansky B, Güldner H, Vogt J, et al. Coronary vein leads for cardiac pacing in patients with tricuspid valve replacement Thorac Cardiov Surg 2002;50:120-121.
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Abstract
Introduction
