IMAGING IN CARDIOLOGY
Asuccessful afternoon's strugge inserting a pacemaker
C.J. Majoor, H.A. Bosker, R Derksen
B
1
Figure 1. A. Venogram ofthe coronarysinusshowingtheposterolateral vein. B. Diagram showing the venogram. 1=rzghtventricularlead; 2=,guiding catheter in the mid cardiac vein, 3=button ofelectrode on the outside of the chest, 4=posterolateral vein.
68-year-old woman was admitted to our hospital in a state of collapse and with complaints ofweakness and dizziness. She had documented paroxysmal atrial fibrillation and heart failure NYHA class III due to a congestive nonischaemic cardiomyopathy, with a left ventricular ejection fraction of 16% and a grade II mitral regurgitation. She was treated with quinapril, A
C.J. Majoor H.A. Bosker R. Desen Department of Cardiology, R,jnstate Hospital, Amhem, the Netherlands Correspondence to: R. Derksen Department of Cardiology, Rijnstate Hospital, PO Box 9555, 6800 TA Amhem, the Netherands E-mail: [email protected]
Netherlands Heart Journal, Volume 14, Number 7/8, August 2006
furosemide, spironolactone, atorvastatin and acenocoumarol. Physical examination revealed a regular bradycardia of 38 beats/min. Her blood pressure was 155/75 mmHg. Examination of the heart showed enlargement; auscultation was quite normal with no obvious murmurs. Rhales were present on both sides, but only in the basal parts of the lungs. No oedema was present. The electrocardiogram showed a sinus tachycardia of 100 beats/min with a total AV block, and a ventricular escape rhythm of38 beats/min. She was indicated for implantation of a dual-chamber pacemaker. Right ventricular apical pacing in a patient with severe left ventricular systolic dysfunction can introduce left ventricular dyssynchrony. Therefore we decided to implant a biventricular pacemaker. After puncture of the left subclavian vein, a persisting left superior caval vein appeared. There was a normal connection with an enlarged coronary sinus 263
IMAGING IN CARDIOLOGY
without a direct connection towards the right caval vein. First the right ventricular lead was actively fixated in the right ventricular septum using a loop in the right atrium. Secondly, a venogram of the coronary sinus was carried out by contrast injection through the guiding catheter selectively placed over the guide wire in the mid cardiac vein (figure 1.) The only vein suitable for introducing a left ventricular lead was a posterolateral vein. This vein drained into the coronary sinus at a sharp angle just proximal to the connection ofthe persisting left superior caval vein and the coronary sinus. This vein could only be selectively cannulated with a mammarian artery catheter (IMA) inserted through the guiding catheter. Then, the guiding catheter was positioned over this IMA catheter, deep in the posterolateral vein, allowing the introduction and positioning ofthe Easytrak-2 lead for the left ventricular pacing. Finally, the atrial lead was actively fixated in the right atrium lateral wall. After fixation of all the leads and connection to the pacemaker, the pacemaker started functioning appropriately
(figure 2). A persisting left superior caval vein develops when the proximal left anterior cardinal vein persists during the normal regression phase. The left anterior cardinal vein develops in the third week of embryogenesis. The proximal part usually obliterates between the 55th and the 60th day to the oblique vein, draining left atrial blood into the coronary sinus. Several anatomical variants of a persisting left superior caval vein have been described: with connections to the coronary sinus, to the right or left atrium, and with and without abnormal insertions of the pulmonary veins." 2 In conclusion, a persisting left superior caval vein does not need to influence the possibility of biventricular pacemaker implantation, it only increases procedure time. -
264
Figure 2. Chest X-ray showing the pacemaker leads (taken in bed). References 1
Ebink C, Bos Uj, Vonken EPA, Velthuis BK, M. Cramer MJM. An unusual presentation with persistent left supenior vena cava. Neth
2
Stokkers PCF, de Ruiter GS, de Voogt WG. Two chamber pacemaker implantation and a persistent left superior caval vein. Neth
HeartJ2004;12:69-71. HeartJ2002;10:286-7.
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one page at the most) to Bohn Stafleu van Loghum, P0 Box 246, 3990 GA Houten, e-mail: [email protected].
Thissection is edited by M.JM Cramer andjj. Bax.
Ncthecrands Heart Journal, Volumec 14, Number 7/8, August 2006
CvC
Asuccessful afternoon's strugge inserting a pacemaker
C.J. Majoor, H.A. Bosker, R Derksen
B
1
Figure 1. A. Venogram ofthe coronarysinusshowingtheposterolateral vein. B. Diagram showing the venogram. 1=rzghtventricularlead; 2=,guiding catheter in the mid cardiac vein, 3=button ofelectrode on the outside of the chest, 4=posterolateral vein.
68-year-old woman was admitted to our hospital in a state of collapse and with complaints ofweakness and dizziness. She had documented paroxysmal atrial fibrillation and heart failure NYHA class III due to a congestive nonischaemic cardiomyopathy, with a left ventricular ejection fraction of 16% and a grade II mitral regurgitation. She was treated with quinapril, A
C.J. Majoor H.A. Bosker R. Desen Department of Cardiology, R,jnstate Hospital, Amhem, the Netherlands Correspondence to: R. Derksen Department of Cardiology, Rijnstate Hospital, PO Box 9555, 6800 TA Amhem, the Netherands E-mail: [email protected]
Netherlands Heart Journal, Volume 14, Number 7/8, August 2006
furosemide, spironolactone, atorvastatin and acenocoumarol. Physical examination revealed a regular bradycardia of 38 beats/min. Her blood pressure was 155/75 mmHg. Examination of the heart showed enlargement; auscultation was quite normal with no obvious murmurs. Rhales were present on both sides, but only in the basal parts of the lungs. No oedema was present. The electrocardiogram showed a sinus tachycardia of 100 beats/min with a total AV block, and a ventricular escape rhythm of38 beats/min. She was indicated for implantation of a dual-chamber pacemaker. Right ventricular apical pacing in a patient with severe left ventricular systolic dysfunction can introduce left ventricular dyssynchrony. Therefore we decided to implant a biventricular pacemaker. After puncture of the left subclavian vein, a persisting left superior caval vein appeared. There was a normal connection with an enlarged coronary sinus 263
IMAGING IN CARDIOLOGY
without a direct connection towards the right caval vein. First the right ventricular lead was actively fixated in the right ventricular septum using a loop in the right atrium. Secondly, a venogram of the coronary sinus was carried out by contrast injection through the guiding catheter selectively placed over the guide wire in the mid cardiac vein (figure 1.) The only vein suitable for introducing a left ventricular lead was a posterolateral vein. This vein drained into the coronary sinus at a sharp angle just proximal to the connection ofthe persisting left superior caval vein and the coronary sinus. This vein could only be selectively cannulated with a mammarian artery catheter (IMA) inserted through the guiding catheter. Then, the guiding catheter was positioned over this IMA catheter, deep in the posterolateral vein, allowing the introduction and positioning ofthe Easytrak-2 lead for the left ventricular pacing. Finally, the atrial lead was actively fixated in the right atrium lateral wall. After fixation of all the leads and connection to the pacemaker, the pacemaker started functioning appropriately
(figure 2). A persisting left superior caval vein develops when the proximal left anterior cardinal vein persists during the normal regression phase. The left anterior cardinal vein develops in the third week of embryogenesis. The proximal part usually obliterates between the 55th and the 60th day to the oblique vein, draining left atrial blood into the coronary sinus. Several anatomical variants of a persisting left superior caval vein have been described: with connections to the coronary sinus, to the right or left atrium, and with and without abnormal insertions of the pulmonary veins." 2 In conclusion, a persisting left superior caval vein does not need to influence the possibility of biventricular pacemaker implantation, it only increases procedure time. -
264
Figure 2. Chest X-ray showing the pacemaker leads (taken in bed). References 1
Ebink C, Bos Uj, Vonken EPA, Velthuis BK, M. Cramer MJM. An unusual presentation with persistent left supenior vena cava. Neth
2
Stokkers PCF, de Ruiter GS, de Voogt WG. Two chamber pacemaker implantation and a persistent left superior caval vein. Neth
HeartJ2004;12:69-71. HeartJ2002;10:286-7.
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one page at the most) to Bohn Stafleu van Loghum, P0 Box 246, 3990 GA Houten, e-mail: [email protected].
Thissection is edited by M.JM Cramer andjj. Bax.
Ncthecrands Heart Journal, Volumec 14, Number 7/8, August 2006
CvC
