Abstract
We present a rare case of a patient with sick sinus syndrome (SSS) due to stab wound, who inadvertently had right atrial appendage (RAA) isolation during ablation. To report a unique technique of a bi-atrial pacing via Y-adaptor with left atrial (LA) lead in the Vein of Marshall (VOM). N/A A 64-year-old male with a stab to the heart underwent two tricuspid valve repairs complicated by RA enlargement and SSS which required permanent pacemaker (PPM). He developed recurrent atypical atrial flutter despite dofetilide use. During mapping his flutter noted to originate from the RAA. While ablating his flutter, it terminated and inadvertently led to RAA isolation. This resulted in lack of RAA pacing signal conducting to rest of atria (including LA and AV node), increasing risk of thrombosis in LA due to atria standstill and chronic RV pacing. Decision was made to restore conduction without compromising RAA pacing. Attempts to deploy to pace the interatrial septum failed due to a very large and scarred RA. The coronary sinus (CS) was cannulated and venogram demonstrated VOM to be too small for a passive lead. A 59 cm active fixation lead was then screwed into the ostium of VOM with good LA pacing threshold (0.7 V at 0.4 ms, 599 ohms). Both atrial leads (RAA and LA/VOM) were then connected via Y-adapter to the RA port of the pacemaker (Figure 1). Bi-atrial pacing threshold was good (1 V at 0.4 ms, 450 ohms). EKG demonstrated successful bi-atrial pacing with RV conduction. RAA isolation in pacer-dependent patients can lead to chronic RV pacing and LA standstill. Y-adapter bi-atrial leads can restore bi-atrial pacing and conduction.
Published Version
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