Ann Thorac Surg 2007;83:1183-1185
© 2007 The Society of Thoracic Surgeons
Case Reports
Successful Use of Transvenous Atrial and Bifocal Left Ventricular Pacing in Ebstein’s Anomaly After Tricuspid Prosthetic Valve Surgery
J. Alberto Lopez, MDa,*,
D. Richard Leachman, MDb
a Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas
b Baylor College of Medicine, Houston, Texas
Accepted for publication August 3, 2006.
* Address correspondence to Dr Lopez, 6624 Fannin, Suite 2780, Houston, TX 77030 (Email: lopezsalas{at}sbcglobal.net).
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Abstract
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A 62-year-old woman with Ebstein’s anomaly and a tricuspid valve prosthesis underwent placement of a permanent atrioventricular pacemaker to treat highly symptomatic sinus node dysfunction and atrioventricular block. Transvenous bipolar leads were placed in the anterior cardiac and lateral coronary veins and were set to optimal ventricular pacing parameters to preserve prosthetic valve function, back-up ventricular pacing, and maintain atrioventricular and interventricular synchrony. An atrial septal lead was placed to control atrial pacing. Interventricular and atrioventricular timing were optimized with the use of tissue Doppler imaging and the Doppler-derived stroke volume.
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Introduction
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Transvenous endocardial pacemaker lead implantation is not advised for patients with mechanical valves in the tricuspid position. Although we, and others [1], have safely implanted a right ventricular pacing lead through a tricuspid valve bioprosthesis, this approach should be avoided if possible. We report a case of successful transvenous lead implantation to achieve atrial septal and bifocal left ventricular pacing by using the anterior cardiac vein for septal and outflow tract pacing and the lateral branch of the coronary sinus. This approach allowed us to maintain atrioventricular synchrony without the risk of tricuspid valve damage, have ventricular back-up pacing in case of lead dislodgement in a patient with symptomatic bradycardia and high-grade atrioventricular block, and preserve interventricular as well as left ventricle mechanical synchrony.
The patient, a 62-year-old woman, was well until 1993 when, at age 38, decreased exercise tolerance and mild cyanosis prompted an echocardiogram and the subsequent diagnosis of Ebstein’s anomaly. Cardiac catheterization revealed an atrial septal defect with a bidirectional shunt and Ebstein’s anomaly. In 1998, at age 43, the patient underwent surgical plication of the atrialized right ventricle, tricuspid valve replacement with a 33-mm Hancock II bioprothesis (Medtronic, Inc, Santa Ana, CA), and patch repair of the atrial septal defect.
She did extremely well until edema, dyspnea on exertion, gastrointestinal symptoms, and right-upper-quadrant discomfort developed 5 months ago. Her cardiac rhythm showed an atypical atrial flutter with 4:1 and 5:1 atrioventricular conduction, yielding a ventricular rate of 50 to 60 beats/min.
The patient underwent 3-dimensional electroanatomic mapping and successful catheter ablation to eliminate macroreentry atrial tachycardia around the atriotomy scar and to restore sinus rhythm. During sinus rhythm, the PR interval was 500 milliseconds, and a proximal His-bundle electrogram recording was not obtainable. Second-degree atrioventricular block was present at 75 beats/min with an isoproterenol infusion of 1.5 mg/min and without atrioventricular conduction-blocking drugs. The patient was monitored for 48 hours, revealing sinus bradycardia (40 beats/min) and intermittent second-degree atrioventricular block with near syncope.
With the patient under local anesthesia and mild sedation, cannulation of the coronary sinus from a left axillary approach was achieved with an Attain sheath (Medtronic Inc, Minneapolis, MN). A balloon occlusion angiogram was then obtained. A bipolar lead (4194-78, Medtronic) was placed in the anterior cardiac vein, resulting in optimal pacing and sensing parameters. A second 4194-78 lead (Medtronic) was placed in the posterolateral branch with the assistance of a second Attain sheath, and optimal pacing parameters were documented. Both sheaths were removed without complication. A 4076-45 bipolar lead (Medtronic) was placed in the interatrial septum anterior to the atrial septal defect patch (Fig 1).
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Fig 1. Chest roentgenogram in the posteroanterior and lateral projections shows the atrial lead at the interatrial septum (left) and two leads in the coronary sinus with bipolar electrodes in the anterior cardiac vein and a posterolateral branch (right).
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Before the patient’s discharge from the hospital, two-dimensional echo Doppler was used to optimize interventricular timing by synchronizing right and left ventricle preejection times (Fig 2). Atrioventricular time was optimized based on resulting stroke volumes, and tissue Doppler imaging was used to assess left ventricle mechanical synchrony (Fig 3). Follow-up evaluation at 7, 30, and 90 days showed normal, functioning leads and significant clinical improvement, with resolution of the patient’s symptoms, hepatomegaly, and edema.
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Fig 2. Continuous-wave Doppler image, obtained at the left ventricular (LV) outflow tract (left) and right ventricular (RV) outflow tract (right), show preejection times and no right-to-left ventricular delay (mechanical interventricular synchrony). (ICT = isovolumetric contraction time.)
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Fig 3. Tissue Doppler images of the lateral and septal walls (left and right views, respectively) at the mitral valve annulus show no significant delay to the peak systolic myocardial velocity in the left ventricle (mechanical intraventricular synchrony). (TD = tissue Doppler.)
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Comment
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Permanent pacemakers are needed by 3.7% of patients born with Ebstein’s anomaly. More than 90% of these patients have undergone tricuspid valve repair or replacement [2]. When a tilting-disc valve is present, placement of endocardial pacing leads across the valve may result in acute valve failure and must be avoided [3]. We, and others [1], have performed successful long-term right ventricular pacing through a right ventricular bioprosthesis, but this approach entails possible leaflet perforation or valve stenosis. Perhaps the most serious complication is the risk of severe valve damage during lead extraction [4]. We consider this risk a relative contraindication to transvalvular right ventricular pacing.
In patients with Ebstein’s anomaly, lead positioning beyond the prosthetic valve with acceptable pacing parameters may not be possible. Bai and colleagues [5] first reported placement of ventricular pacing leads in the coronary veins in a patient with a tricuspid prosthesis. Since then, the development of left ventricular pacing leads has facilitated this approach and significantly decreased the rate of lead dislodgement; therefore, a minimally invasive approach should always be considered before epicardial lead placement.
To avoid inducing further right ventricular dyssynchrony, we targeted the anterior cardiac vein to stimulate the basal interventricular septum and outflow tract early and to improve right atrial and right ventricular timing. The posterolateral vein was used to preserve left intraventricular synchrony and to increase safety in case of anterior lead dislodgement and loss of ventricular capture. Atrial septal pacing decreased the abnormal interatrial conduction time related to the baseline disease and previous surgical procedures, thus avoiding left atrial–left ventricular dyssynchrony. To optimize pacemaker programming, cardiac Doppler-derived hemodynamic parameters (stroke volume and trans mitral flow velocities) as well as cardiac tissue Doppler-derived mechanical synchrony indices (time to peak systolic velocity and delay longitudinal contraction) can be easily used and are readily available.
In conclusion, pacemaker therapy after tricuspid valve surgery still presents challenges. If possible, lead placement through a bioprosthetic valve should be avoided. With current lead technology, experienced physicians can successfully achieve atrial and ventricular pacing with predictable results. This approach can prevent the morbidity and mortality associated with epicardial lead placement and can provide physiologically appropriate pacing therapy, improving the resulting cardiac output. The presence of a second ventricular lead will add safety owing to back-up pacing in case of lead dislodgement and, possibly, will reduce detrimental pacemaker-induced ventricular remodeling and the resulting hemodynamic abnormalities.
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References
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- Pernenkil R, Wright JS. Endocardial pacing through a prosthetic tricuspid valve Pacing Clin Electrophysiol 1990;13:1365-1366.[Medline]
- Allen MR, Hayes DL, Warnes CA, Danielson GK. Permanent pacing in Ebstein’s anomaly Pacing Clin Electrophysiol 1997;20:1243-1246.[Medline]
- Davidson NC, Mond HG. Ventricular pacing in the presence of tricuspid valve disease Pacing Clin Electrophysiol 2002;25:129-131.[Medline]
- Assayag P, Thuaire C, Benamer H, Sebbah J, Leport C, Brochet E. Partial rupture of the tricuspid valve after extraction of permanent pacemaker leads: detection by transesophageal echocardiography Pacing Clin Electrophysiol 1999;22:971-974.[Medline]
- Bai Y, Strathmore N, Mond H, Grigg L, Hunt D. Permanent ventricular pacing via the great cardiac vein Pacing Clin Electrophysiol 1994;17:678-683.[Medline]
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Abstract
Introduction
