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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
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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.