Download cardiac resynchronization therapy (crt) system with implantation of

CARDIAC RESYNCHRONIZATION THERAPY
(CRT) SYSTEM WITH IMPLANTATION OF
TWO LEFT VENTRICULAR ELECTRODES IN
A PATIENT WITH IDIOPATHIC DILATIVE
CARDIOMYOPATHY
Sv. Iovev, Y. Dzhorgova, B. Slavchev, M. Stoilova
UNSHAT “St. Ekaterina” – Sofia
Author for contacts: Sv. Yovev, MU – Sofia, Clinic of Cardiology, Department of Electrocardiostimulation and Electrocardiophysiology,
UNSHAT “St. Ekaterina”, 52A Pencho Slaveikov Blvd. – Sofia, Bulgaria; tel: +359 2 915 97 24, e-mail: [email protected]
Abstract: We present a clinical case of a 54-year-old woman with а successfully implanted cardiac resynchronization
therapy system – CRT–P, who suffered a spontaneous perforation of the right ventricle electrode 36 hours after the procedure,
followed by an emergency thoracotomy.
Case Report
We present a 54-year-old female patient, BMI, diagnosed with Idiopathic Dilative Cardiomyopathy (IDC),
left bundle branch block (LBB), heart failure (HF) functional class III NYHA – refractory to drug therapy, renovascular hypertension based on fibromuscular dysplasia of the right renal artery with stent implantation of
the right renal artery.
From the clinical investigations: the selective coronary angiography (SCAG) found intact coronary arteries, the electrocardiography (ECG) - sinus rhythm,
LBB, duration of the ventricular complex 140 ms; the
echocardiography (EchoCG) - diffuse hypokinesia, telesystolic volume of the left ventricle (TSV-LV) – 52 mm,
telediastolic volume of the left ventricle (TDV–LV) –
66 mm, left ventricle ejection fraction (LVEF) - 30% by
Simpson’s method, mitral insufficiency (MI) – 1st grade,
normal right cavities without pulmonary arterial hypertension (PAH) at rest. Tissue doppler data for intraventricular and interventricular dyssynchrony.
In 2009, in a condition of stable hemodynamic and
under local anesthesia the patient was implanted with
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a cardiac resynchronization therapy system - model
“Stratus LV-T” (Biotronik), using left subclavian vein
access. The retrograde venography of the coronary
sinus revealed the presence of a powerful Vieussens
valve, preventing visualization of the coronary sinus
anatomy, as well as a presence of posterior branch
– PIV (Posterior Interventricular Vein) (Fig.1 and 2).
There was an unsuccessful attempt for intubation
of the GCV (great cardiac vein) with an electrophysiological catheter type RAPIDO and a percutaneous
coronary angioplasty guidant system (PTCA). This led
to implantation of a left ventricular electrode in PIV
of the coronary sinus. Inserted and placed was a left
ventricular lead “Corox 70 – BP” (Biotronik) at optimal
position – bypassing at maximum the heart’s apex. A
right ventricular lead with active fixation model “Selox
53-BP” was inserted and placed through the left subclavian vein in the output tract of the right ventricle
on midseptal position. Electrodes for right atrium
model “Selox 63-BP” with active fixation were placed
in standard position – auricle of the right atrium. Registered were optimal parameters for stimulation and
sensing of the left ventricle, right ventricle and right
atrium (fig.3).
J Clin Med. 2010; 3(1):40-42
CS – coronary sinus Fig. 1
There were no complications during and after the procedure – no pneumothorax, no ultrasonography signs
for pericardial and pleural effusion on the 24th hour.
RA – right atrium
RV – right ventricle
LV – left ventricle
Fig. 3
Fig. 2
PIV – posterior interventricular vein
On the 36th hour after implantation occurred an attack of heavy, continuous and irritating cough which
lasted for about 30 min. Afterwards there appeared a
strong retrosternal pain, followed by a collapse on the
60th min. The ultrasonography investigation revealed a
haemothorax, cardiac tamponade and an emergency
thoracotomy was required.
After draining large pericardial and pleural hemorrhagic effusions, a dislocation of the right ventricular
and right atrium electrodes was revealed, with perforation of the right ventricle. An extirpation of the
electrodes was performed, followed by suturing of the
right ventricle. Intraoperatively, a new epicardial left
ventricular electrode “Mayo Dex” was placed, with bipolar stimulation threshold of 0.5 V, 700Oms impedance and sensing 17mV (fig.4). Postoperatively, the
patient was extubated with compensated blood loss
and a stable hemodynamic. On the second day after the surgery, under local anesthesia and using left
subclavian vein access, a new right atrium electrode
“DP-Isoflex” was inserted and placed with stimulation
threshold 0.3 V, impedance 490ms and sensing 3.5mV.
Optimal parameters of stimulation were registered for
the left ventricular electrode in the posterior branch of
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RA – right atrium
Fig. 4
LV – left ventricle
PIV – posterior interventricular vein
the coronary sinus: threshold 0.8 V, impedance 500ms
and sensing 14mV. There were no signs for intra– and
post procedure complications.
On the 7th day the EchoCG demonstrated improved
synchronicity of the left ventricle with some reduction
of the measured volumes: telesystolic volume (TSV) =
93ml and EF – 33%. The patient was mobilized and
discharged from the hospital on the 10th postoperative
day. The discharge ECG examination presented: permanent sequential biventricular/dual chamber DDDR
stimulation.
One month after the surgery a tissue Doppler follow
up heart evaluation was performed, which registered
a significant improvement of the pump function: EF –
42% with additional reduction of the TSV of 70ml with
ongoing resynchronized biventricular stimulation. On
the 3rd month after the implantation, the EF of the left
ventricle was 58%.
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Discussion:
The use of cardiac resynchronization therapy systems
for stimulation is associated with both intra-procedure
problems and post-procedure complications.
Spontaneous perforation of the right ventricular
electrode is a rarely observed defect in this type of
medical product. The application of leads with active
fixation increases the risk of such complication, which
is more common in the defibrillation types, due to
their greater rigidity.
In this case, the onset of the new complaints is 36
hours after the procedure. As a possible trigger may
be considered the heavy cough, which preceded the
occurrence of the strong retrosternal pain, as per the
case history.
Our conclusion, taking into consideration the described dynamics, is that the monitoring of the general condition and hemodynamic parameters of such
patients needs to be not less than 48 hours after the
procedure.