3 TGKD kapak 17-1.qxp - turkinvasivecard.org
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3 TGKD kapak 17-1.qxp - turkinvasivecard.org
TGKD Cilt 17, Sayı 1 Şubat 2013:31-33 Duyuler ve ark. Pectoral muscle stimulation 31 PECTORAL MUSCLE STIMULATION PROBLEM SECONDARY TO EPICARDIAL ELECTRODE IN A PATIENT WITH TRICUSPID VALVE PROSTHESIS SOLVED WITH CORONARY SINUS PACING *Serkan Duyuler MD., **Türker P MD., ***Güray Ü MD., ***Kısacık L.H MD. *Hakkari State Hospital, Cardiology Clinic, Hakkari,**Muş State Hospital, Cardiology Clinic, Muş, ***Turkiye Yuksek Ihtisas Hospital,Cardiology Clinic, Ankara Günümüzde neredeyse tüm kalıcı kalp pili elektrotları transvenöz yolla takılmaktadır. Metalik triküspit protezi mevcudiyeti mutlak kontrendikasyon olmasa da, transvenöz endokardiyal elektrot yerleştirilmesini komplike edebilmektedir. Bu gibi durumlarda epikardiyal elektrod yerleştirilmesi bir seçenektir. Epikardiyal elektrot yerleştirilmesi torakotomi gerektirir ve daha önce toratokotomi öyküsü olan hastalarda komplikasyon riski yüksektir.Kalıcı kalp pilllerinin ekstrakardiyak uyarı yapması iyi bilinen durumlardır ancak pektoral kas uyarımı oldukça nadirdir. INTRODUCTION In current clinical practice, almost all pacemaker electrodes are placed via transvenous route. The presence of a metallic tricuspid prosthesis is not an absolute contraindication to the passage of an endocardial ventricular lead, however, presence of a metallic prosthetic valve in tricuspid position may complicate placement of transvenous endocardial electrode 1. Generally, an epicardial electrode is used in this setting instead of transvenous endocardial electrode. Occurrence of unfavorable conditions such as epicardial electrode dysfunction may necessitate alternative routes. In this case report we described a rare indication for alternative route of pacing in a patient with mechanical tricuspid valve in whom coronary sinus electrode substituted for epicardial electrode stimulating skeletal muscles. CASE REPORT A 58-year- old female patient was admitted to our clinic with complaint of involuntary muscle contraction Yazışma Adresi: Serkan DUYULER, MD Hakkari Devlet Hastanesi Kardiyoloji Kliniği, Dağgöl Mahallesi, Hastane caddesi, Hakkari Tel: +90 438 211 60 67- 1307 Fax: +90 438 211 71 92 e-mail: [email protected] Geliş Tarihi:24.07.2012 Kabul Tarihi:28.09.2012 Bu yazıda epikardiyal kalıcı kalp pili elektrodu disfonksiyonuna bağlı pektoral kas stimulasyonu olan, triküspit kapak protezli hastada alternatif bir yöntem olarak koroner sinus yoluyla uyarımı sunulmuştur. Anahtar kelimer: Triküspid kapak protezi, Koroner sinüs pacing, Pektoral adele stimulasyonu, Epikardiyal elektrod (Türk Girişimsel Kard. Der. 2013;17:31-33) in left arm. In her medical history, she had undergone metallic monoleaflet mitral valve replacement 20 years ago and metallic bileaflet tricuspid valve replacement three years ago. Two years ago, she developed symptomatic 3rd degree AV block and VVIR pacemaker implantation was performed via epicardial way since Figure 1: Electrocardiogram showing pacemaker rhythm with unipolar spikes via epicardial electrode. 32 Duyuler ve ark. Pectoral muscle stimulation TGKD Cilt 17, Sayı 1 Şubat 2013:31-33 Figure 2: Chest x-ray after coronary sinus electrode placement. Figure 3: Electrocardiogram showing pacemaker rhythm via coronary sinus electrode pacing. she had a metallic prosthesis in tricuspid position. Although pacemaker seemed to function properly, she has been complaining muscle contractions in the left arm which had begun soon after epicardial pacemaker implantation. These contractions were simultaneous with apical heartbeat. Electrocardiography revealed pacemaker rhythm with unipolar pace spikes (Figure 1). Skeletal muscle stimulation secondary to epicardial pacing was considered and reduction of voltage output and prolongation of pulse width was scheduled initially. Patient's complaints persisted despite the re- adjustment. Rather than revision of the unipolar pacing electrode with thoracic surgery, implantation of coronary sinus electrode was scheduled to avoid an additional thoracic surgery in this patient who had already undergone three cardiac operations. A coronary sinus electrode was placed via left subclavian vein following the coronary sinus venogram. Existing pace maker generator was replaced with a VVIR pace maker and head of retained epicardial electrode was covered with cap (Figure 2). Initial pace parameters were as follow: R wave: 20 mV, pacing threshold: 1.7 V and impedance: 1500 ohm. No complications were observed except small hematoma which resolved with tight compress. Electrocardiography following coronary sinus electrode implantation is shown in Figure 3. Skeletal muscle stimulations ceased after procedure and did not recur during follow-up. She was dis- charged after two days when effective anticoagulation with warfarin was achieved. In the first month follow-up visit, pacemaker electrode and pacing parameters were stable and she was asymptomatic. DISCUSSION Epicardial electrode implantation, which was applied more frequently in the earliest pacemaker implantations, is preferred in a limited group of patients in contemporary clinic practice. In patients with tricuspid valve prosthesis epicardial electrode implantation is favored2. However problems such as high pacing thresholds, electrode fracture and extra cardiac stimulation may relatively be observed more frequently during follow-up. Extra cardiac stimulation of the pacemaker involves diaphragmatic and pectoral muscle stimulation. Pectoral muscle stimulation is secondary to unipolar electrode contacting the muscle or current leakage from fractured electrode to surrounding tissues. Although this complication is not vital, it may lead early depletion of batteries and these involuntary contractions would be annoying for the patient. Reduction of voltage output and pulse width may cease the pectoral muscle stimulation. However reduction of these parameters did not cease contractions in our case and other alternatives were considered. Revision of epicardial electrode may be an option, but necessity for general anesthesia and thoracotomy is significant disadvantages of TGKD Cilt 17, Sayı 1 Şubat 2013:31-33 Duyuler ve ark. Pectoral muscle stimulation this approach. Also adhesions secondary to previous cardiac operations may lead ventricular injury during epicardial electrode placement. Besides, epicardial approach is related with longer hospital stay and lead failure in patients with history of cardiac surgery3. Coronary sinus electrodes are widely used for biventricular pacing in cardiac resynchronization therapy. On the other hand, displacement of coronary sinus leads is still much higher than endocardial ventricular leads in those without tricuspid prostheses which may complicate pace dependent patients4. As we experienced in our case, coronary sinus pacing is an eligible route when right ventricular endocardial pacing via tricuspid valve is not suitable and should revision for epicardial electrode be avoided. interventions such as revision of electrodes, reoperation or use of other alternative routes for pacing. In this case, coronary sinus pacing is an alternative effective option. REFERENCES 1. 2. 3. CONCLUSION This case report is educative for some reasons. First, epicardial pace electrodes, specifically unipolar electrodes, may be associated with involuntary pectoral muscle contractions even electrode integrity and functions are preserved. Second, these contractions may be cumbersome for patient and necessitates 33 4. Yoda M, Nakai T, Okubo K, Hata M, Sezai A, Hirayama A, Minami K. First case report in Japan of left ventricular pacing via a coronary vein in a patient with a mechanical tricuspid valve. Circ J. 2008;72:335-36. Tıkız H. Kalıcı kap pilleri ve elektrodlar. In: Oto A, Aytemir K, et al. Editors. Kalıcı kalp pilleri ve implante edilebilir defibrilatörler. Ankara: Erkem tıbbi yayıncılık: 2006.p.3-18. Lau EW. Achieving permanent left ventricular pacing-options and choice. Pacing Clin Electrophysiol. 2009;32:1466-77. Fuertes B, Toquero J, Arroyo-Espliguero R, Lozano IF. Pacemaker lead displacement: mechanisms and management. Indian Pacing Electrophysiol J. 2003;3:231-38.
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