Dual-chamber Permanent Pacemaker Research Articles

Amorous overheating?

In March, 2009, a 54-year-old man attended the pacemaker clinic for routine review. He described a 20-month history of intermittent episodes of rigors and fevers (temperatures up to 39·3°C) associated with myalgia and arthralgia predominantly related to severe physical exertion and sexual intercourse. His medical history included: a dual chamber permanent pacemaker (PPM) implant for sinus node dysfunction in 1992; a change of generator box in 2006; and melanoma excision in 2007. 18 months earlier he had undergone lumbar laminectomy and 6-week treatment with flucloxacillin for discitis due to coagulase-negative staphylococcus. Over the following months he presented to several specialists for investigations of these symptoms.

A Case of the Giant Thrombus on Atrial Lead of a Patient Who Has a DDD Permanent Pacemaker

We report a case of the giant thrombus on atrial lead of a patient who has a DDD dual-chamber permanent pacemaker.

Infra-Hisian block as cause of Wenckebach's phenomenon in an asymptomatic middle-aged man

We report the case of a 60-year-old man with asymptomatic sinus bradycardia and Holter recording showing episodes of Wenckebach block alternating with episodes of 2:1 block. Electrophysiological testing revealed Infra-Hisian block with progressive prolongation of the H-V interval resulting in block after H potential. This produced typical Wenckebach-type block on surface electrocardiogram resembling the clinical one. The patient was successfully treated with permanent dual-chamber pacemaker implantation.

Relatively narrow QRS complex after magnet application: what is the mechanism?

A 63-year-old man with sick sinus syndrome, who underwent dual-chamber permanent pacemaker implantation, was admitted due to frequent episodes of palpitation as a result of pacemaker-mediated tachycardia (PMT) ( Figure 1A ), which is terminated by magnet application ( Figure 1B …

Diagnosis of Prosthetic Aortic Valve Endocarditis With Gallium-67 Citrate Single-Photon Emission Computed Tomography/Computed Tomography Hybrid Imaging Using Software Registration

Prosthetic valve endocarditis can be challenging to diagnose and is associated with high mortality rates even if recognized and managed early. We present a case of staphylococcal sepsis soon after aortic valve surgery and permanent pacemaker implantation for which conventional investigation with echocardiography and computed tomography (CT) failed to identify an infective focus. Subsequent gallium–single-photon emission CT (67Ga-SPECT) imaging with software registration of the SPECT data helped to correctly identify the prosthetic aortic value as the source of sepsis, with resolution of changes on subsequent imaging. A 70-year-old woman underwent bioprosthetic aortic valve replacement and coronary artery bypass grafting for symptomatic severe aortic stenosis and significant 2-vessel coronary disease. Her postoperative course was complicated by significant bradycardia necessitating dual-chamber permanent pacemaker implantation. She presented 3 months after surgery in a confused state, with low-grade pyrexia. The examination identified a soft systolic aortic murmur but no diastolic component, normal breath sounds, absence of cutaneous markers of endocarditis, and no evidence of …

Trends of permanent pacemaker implantation in University Cardiac Center, BSMMU

The purpose of the study was to investigate the trends of permanent pacemaker implantations in the University Cardiac Center (UCC), Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka. This retrospective study conducted in the department of Cardiology, UCC, BSMMU, Dhaka to evaluate demographic distribution, indications, complications of the permanent pacemaker (PPM) implantation and its hospital outcome. Data of this retrospective study was collected from hospital registry and patient's record files. Total 98 patients were studied. Among them male were 64.28% (n=63) and female were 35.71% (n=35). Most of them were elderly patients (58%). Complete heart block was the most common cause for PPM implantation, which was 67.35% (n=66). Single chamber multiprogrammable PPM (VVI) was implanted in 86.73% (n=85) and Dual chamber PPM (DDI) was implanted in 13.26% (n=13) cases. No Major complications occurred during the procedure and short term in-hospital outcome was good for all the cases. This study showed that PPM implantation is rapidly increasing modality of treatment for patients with cardiac bradyarrhythmias as effective technique with good in-hospital outcome. Â doi:10.3329/uhj.v4i2.2072 University Heart Journal Vol. 4 No. 2 July 2008 p16-18

A supraventricular tachycardia: What is the mechanism?

A 93 year old female presented for an electrophysiology study and possible catheter ablation for two syncopal episodes, one associated with facial injury. Previously, she had undergone placement of a dual chamber permanent pacemaker for sinus bradycardia, and subsequent interrogation of the device revealed several episodes of tachycardia with a one to one V-A relationship. Holter monitoring confirmed that these episodes represented a supraventricular tachycardia (SVT).

Determination of myocardial energetic output for cardiac rhythm pacing

This research is aimed to the determination of the changes in the cardiac energetic output for three different modes of cardiac rhythm pacing. The clinical investigation of thirteen patients with the permanent dual-chamber pacemaker implantation was carried out. The patients were taken to echocardiography examination conducted by way of three pacing modes (AAI, VVI and DDD). The myocardial energetic parameters—the stroke work index (SWI) and the myocardial oxygen consumption (MVO2) are not directly measurable, however, their values can be determined using the numerical model of the human cardiovascular system. The 24-segment hemodynamical model (pulsating type) of the human cardiovascular system was used for the numerical simulation of the changes of myocardial workload for cardiac rhythm pacing. The model was fitted by well-measurable parameters for each patient. The calculated parameters were compared using the two-tailed Student’s test. The differences of SWI and MVO2 between the modes AAI and VVI and the modes DDD and VVI are statistically significant (P < 0.05). On the other hand, the hemodynamic effects for the stimulation modes DDD and AAI are almost identical, i.e. the differences are statistically insignificant (P > 0.05).

Massive arm edema following arteriovenous dialysis shunt creation in a patient with ipsilateral permanent pacemaker

Asymptomatic subclavian vein occlusion following insertion of a permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) is not uncommon. We report a case of a dual-chamber PPM in a patient with an unrecognized left subclavian vein occlusion who developed massive left arm edema following ipsilateral implantation of an arteriovenous (AV) hemodialysis graft. We recommend that patients with pre-existing PPM or ICD leads who are in need of vascular access for hemodialysis should have the AV shunts placed in the contralateral arm. If this is unavoidable, then preoperative subclavian vein screening for patency should be mandatory, even in asymptomatic patients. Sonography is an appropriate initial test in such a situation.

P-Wave Morphology Assessment by a Gaussian Functions-Based Model in Atrial Fibrillation Patients

Aim of this study was to present a P-wave model, based on a linear combination of Gaussian functions, to quantify morphological aspects of P-wave in patients prone to atrial fibrillation (AF). Five-minute ECG recordings were performed in 25 patients with permanent dual chamber pacemakers. Patients were divided into high-risk and low-risk groups, including patients with and without AF episodes in the last 6 mo preceding the study, respectively. ECG signals were acquired using a 32-lead mapping system for high-resolution biopotential measurement (ActiveTwo, Biosemi, The Netherlands, sample frequency 2 kHz, 24-bit resolution). Up to 8 Gaussian models have been computed for each averaged P-wave extracted from every lead. The P-wave morphology was evaluated by extracting seven parameters. Classical time-domain parameters, based on P-wave duration estimation, have been also estimated. We found that the P-wave morphology can be effectively modeled by a linear combination of Gaussian functions. In addition, the combination of time-domain and morphological parameters extracted from the Gaussian function-based model of the P-wave improves the identification of patients having different risks of developing AF.

An Unusual Case of Embolic Stroke After Permanent Pacing

HomeCirculationVol. 115, No. 14An Unusual Case of Embolic Stroke After Permanent Pacing Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBAn Unusual Case of Embolic Stroke After Permanent Pacing Tim Lockie, BSc, MBChB, Azad Ghuran, MD and David Hildick-Smith, MD Tim LockieTim Lockie From the Sussex Cardiac Centre, Brighton, United Kingdom. Search for more papers by this author , Azad GhuranAzad Ghuran From the Sussex Cardiac Centre, Brighton, United Kingdom. Search for more papers by this author and David Hildick-SmithDavid Hildick-Smith From the Sussex Cardiac Centre, Brighton, United Kingdom. Search for more papers by this author Originally published10 Apr 2007https://doi.org/10.1161/CIRCULATIONAHA.106.639336Circulation. 2007;115:e386–e387A 54-year-old Caucasian male transatlantic airline pilot with no cardiovascular risk factors presented to a neurology clinic after a transient episode of dysphasia. He reported no additional neurological symptoms. Eleven years previously, he had developed asymptomatic sinus node disease and had undergone implantation of a dual-chamber permanent pacemaker to retain his commercial pilot’s license. He was in sinus rhythm, was normotensive (120/70 mm Hg), and had no cardiac murmurs or carotid bruits. Neurological examination was normal.A computerized tomography scan of his head showed a focal left cerebral infarct. Carotid ultrasonography, holter monitoring, and a thrombophilia screen were normal. A diagnosis of a left-hemisphere transient ischemic event was made. The patient was referred for a transoesophageal echo to exclude an intracardiac source of embolus. Structurally, the heart was normal, but on venous bubble contrast injection from the left arm, there was dense simultaneous opacification of both the left and right sides of the heart, without Valsalva maneuvers (Figure 1). Transthoracic images were subsequently repeated with bubble contrast from the right arm; on this occasion, there was no opacification of the left side of the heart, even with Valsalva maneuvers, effectively excluding a significant patent foramen ovale or intrapulmonary arteriovenous malformation (Movie I). Download figureDownload PowerPointFigure 1. Transesophageal echocardiography and bubble study illustrates bubbles entering the left atrium (LA) before the right atrium (RA). Ao indicates aorta.The patient underwent a venogram from the left basilic vein (Figure 2). This demonstrated a proximal occlusion of the left subclavian vein (in which the 2 pacing leads ran), 2 small collaterals crossing the mediastinum into the superior vena cava (which remained fully patent), and 1 large serpiginous collateral from the subclavian vein at the level of the occlusion draining directly into the left upper pulmonary vein. Download figureDownload PowerPointFigure 2. A, Venogram from the left arm illustrating an occluded left subclavian vein (LSCV) containing the pacing leads, with collaterals and a fistulous connection to the left atrium (LA). SVC indicates superior vena cava. B, Fistula occluded with an Amplatzer vascular plug (AVP).The patient was anticoagulated. In view of likely paradoxical embolization through the venovenous right-to-left shunt, the patient was readmitted for closure of the collateral vessel. A 6-mm Amplatzer vascular plug (AGA Corporation, Plymouth, Minn) was deployed via a guide catheter from the left basilic vein, with complete closure of the collateral channel. Repeat contrast echocardiography the next day showed no residual shunt. The patient remains well with no further symptoms, but he has not been able to return to his former employment.Occlusion of the access vein is a recognized complication of permanent pacing, with an incidence of 15% to 30%,1 unrelated to lead size or number.2 This occlusion rarely causes symptoms because venous collaterals quickly develop. Systemic-to-pulmonary venovenous collaterals have been reported in superior venacaval obstruction3 but not with subclavian vein occlusion alone. It represents a rare but important potential complication from transvenous pacemaker lead implantation.The online-only Data Supplement, consisting of Movies I and II, is available with this article at http://circ.ahajournals.org/cgi/content/full/115/14/e386/DC1.DisclosuresNone.FootnotesCorrespondence to Tim Lockie, BSc, MBChB, Flat 6, 32 Coin St, London SE1 8YG, UK. E-mail [email protected]References1 Rozmus G, Daubert JP, Huang DT, Rosero S, Hall B, Francis C. Venous thrombosis and stenosis after implantation of pacemakers and defibrillators. J Interv Card Electrophysiol. 2005; 13: 9–19.CrossrefMedlineGoogle Scholar2 Bracke F, Meijer A, Van Gelder B. Venous occlusion of the access vein in patients referred for lead extraction: influence of patient and lead characteristics. Pacing Clin Electrophysiol. 2003; 26: 1649–1652.CrossrefMedlineGoogle Scholar3 Ho HT, Horowitz AL, Ho AC. Systemic to pulmonary venous communication (right-to-left shunt) in superior vena cava obstruction demonstrated by spiral CT. Br J Radiol. 1999; 72: 712–713.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails April 10, 2007Vol 115, Issue 14 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.106.639336PMID: 17420355 Originally publishedApril 10, 2007 PDF download Advertisement SubjectsAnticoagulantsCerebrovascular Disease/StrokeEchocardiographyImagingPacemakerTransient Ischemic Attack (TIA)

Constrictive Pericarditis Diagnosed by Cardiac Magnetic Resonance Imaging in a Pacemaker Patient

A 71-year-old male was referred for evaluation of 6 months of progressively worsening dyspnea on exertion and peripheral edema, mainly of the legs. During the symptomatic period, he had undergone 3 thoracentesis procedures, each draining more than 1500 mL of transudative fluid. His functional impairment was so severe that he contemplated suicide. His cardiac history was significant for syncope attributable to sinus node dysfunction 19 years earlier, requiring implantation of an atrioventricular pacing system. Because of atrial lead fracture, a second atrial lead had been placed 1 month before the onset of the dyspnea and leg edema. Physical examination revealed diminished breath sounds over both lung fields and moderate (2+) edema of both lower extremities to the level of the knee. The 12-lead ECG demonstrated normal sinus rhythm at 79 bpm with low-voltage and diffuse ST and T-wave abnormalities (Figure 1). A chest x-ray revealed a dual-chamber permanent cardiac pacemaker, 2 retained leads, and bilateral pleural effusions (Figure 2). Transthoracic and transesophageal echocardiography and …

Early Detection of Perforation of the Right Ventricle by a Permanent Pacemaker Lead

Ventricular perforation is a rare complication of permanent cardiac pacemaker implantation. We report here on a 68-year-old woman with a dual chamber permanent pacemaker that had been implanted one month earlier, and she suffered cardiac perforation from the pacemaker lead. Frequent follow-up via12-lead surface electrocardiography and chest radiography and the proper work-up for pacemaker implantation are needed for detecting rare complications after pacemaker implantation. (Korean Circulation J 2007;37:453-457)

Persistent left‐sided superior vena cava – a pacing challenge

A left sided superior vena cava (LSVC) occurs in 0.3% of the population. LSVC normally drains into the right atrium through a dilated coronary sinus. We illustrate two cases of dual chamber permanent pacemaker implantation by using (1) left subclavian vein in a 35-year-old woman with symptomatic Mobitz type II atrioventricular block; and (2) right subclavian vein in a 64-year-old man who was hospitalized with bradycardia, complete heart block, and alternating bundle branch block. After accessing the subclavian vein, the pacing leads were advanced into the LSVC, which was situated to the left of the vertebral column in the mediastinum. The leads followed the course of the LSVC medially before entering into the right atrium. Once inside the right atrium, the ventricular lead made a U-turn towards the tricuspid valve and into the right ventricle by shaping the stylet, and it was helped by right atrial contraction. An active fixation atrial lead was used in both cases to secure a satisfactory location within the right atrium. A small volume of contrast can be injected into the pacing sheath to visualize the coronary sinus opening into the right atrium, and the right ventricle. Fluoroscopy in oblique views can be helpful in guiding the atrial lead into the anteriorly positioned atrial appendage. In emergency transvenous ventricular temporary pacing where the subclavian or internal jugular vein is used, it is important to recognize the presence of a LSVC. The lead should first be directed into the right atrium and then looped back into the right ventricle. Excessive force must be avoided to prevent cardiac perforation and tamponade. If this is not successful, access through a femoral vein should be attempted.

EXERCISE-INDUCED ASYSTOLE WITH SYNCOPE IN A HEALTHY YOUNG MAN.

Purpose Exercise-related syncope is frequently an ominous symptom associated with advanced cardiovascular disease. Asystole during or following exercise is a rare occurrence in persons with structural heart disease and is an even rarer cause of syncope in healthy persons. Neurocardiogenic syncope describes a loss of consciousness resulting from impaired cerebral perfusion due to abnormal autonomic activity. It is expressed in two forms: the more common vasodepressor variant with abnormal regulation of systemic vascular resistance and a vagal variant with inappropriate cardiac slowing related to augmented vagal nerve activity. Case Report Herein we report on a healthy 40-year-old male who was hospitalized after a syncopal episode that followed his playing basketball. He recalled several near-syncopal episodes after strenuous exercise over the past 6 months during which time he used marijuana, but not alcohol or cocaine, and was not receiving prescribed medications or taking across-the-counter agents. Cardiopulmonary disease was not detected by either physical examination or various investigatory studies. Ten minutes of monitored, incremental treadmill exercise test was associated with a rise in heart rate to 137 bpm (from a resting bradycardia of 51 bpm) and blood pressure to 144/74 (136/78 mm Hg at rest). During the immediate recovery period, sinus bradycardia appeared at 30 seconds followed by a 7-second period of sinus arrest and ventricular asystole with syncope. Consciousness returned thereafter with the spontaneous appearance of sinus tachycardia (109 bpm). The presumptive vagal origin of his sinoatrial arrest and asystole prompted placement of a dual-chamber permanent pacemaker. No further syncopal episodes have been reported, despite his continued participation in basketball and smoking marijuana. Discussion The loss of sinoatrial activity and appearance of ventricular asystole immediately following strenuous exercise are in keeping with the vagal variant of neurocardiogenic syncope. Such parasympathetic dominance could be related to (a) his recent, chronic cannabinoid use, where experimental studies have shown cannabidiol produces bradycardia and asystole; (b) an “insufficient” release of a vagal inhibitor, neuropeptide Y during exercise; or (c) a cannabinoid-neuropeptide interaction, which has been identified to occur in the hypothalamus.

Safety of nerve conduction studies in patients with implanted cardiac devices

Patients with implanted cardiac devices and their physicians may defer important electrodiagnostic testing because of anxiety about potential negative effects on the device. To determine the safety of routine nerve conduction studies (NCS) in this population, 10 patients with permanent dual-chamber pacemakers of various types and five patients with implanted cardiac defibrillators (ICD) underwent nerve stimulation at sites commonly used during NCS. The implanted cardiac device was interrogated before and after the study and there was continuous monitoring of the surface electrocardiogram (ECG) and atrial and ventricular electrograms. Electrical impulses generated during routine NCS were never detected by the sensing amplifier and did not affect the programmed settings of the implanted cardiac device. We conclude that routine NCS is safe in patients with implanted cardiac pacemakers with bipolar sensing configurations and defibrillators.

Pathophysiology and Management of Syncope in Kearns-Sayre Syndrome

A 20-year-old woman with known Kearns-Sayre syndrome was transferred to the emergency department due to syncopal episodes. The electrocardiogram on admission showed complete atrioventricular block. The diagnosis of mitochondrial encephalomyopathy was made when she was 14 years old. At the time of the initial diagnosis, she displayed a normal electrocardiogram pattern. At the age of 17, electrocardiogram recordings demonstrated right bundle branch block with left anterior fascicular block and a prolonged QTc interval of 485 milliseconds (Figure). She was taking coenzyme Q10, oral nicotinamide adenine dinucleotide (reduced), piribedil, amantadine, and primidone. Transthoracic echocardiography revealed normal wall motion of both ventricles and mitral valve prolapse without regurgitation. A permanent dual-chamber pacemaker was immediately implanted.

Recovery of Left Ventricular Systolic Function After Biventricular Resynchronization Pacing in a Child With Repaired Tetralogy of Fallot and Severe Biventricular Dysfunction

A 5-year-old child had undergone surgical repair of a ventricular septal defect and pulmonary stenosis at the age of 4 months. The repair required a total of 3 episodes of cardiopulmonary bypass and was complicated by complete atrioventricular block. Subsequently, a permanent dual-chamber pacemaker was implanted, with epicardial leads on the right atrium and the right ventricular outflow tract. Late postoperative complications included atrial ectopic tachycardia, controlled with amiodarone, and progressive left ventricular systolic dysfunction, treated with increasing doses of digoxin, captopril, furosemide, and hydrochlorothiazide-spironolactone. The patient was referred to our center for ongoing …

Diagnostic Dilemma: A Pacemaker Lead Inside the Left Atrium or an Echocardiographic Beam Width Artifact?

A 71-yr-old man with a permanent dual chamber pacemaker (pm), chronic atrial fibrillation with a slow ventricular response and symptomatic mitral regurgitation presented for mitral valve surgery. His intraoperative monitoring included, among others, a pulmonary artery catheter (PAC) and transesophageal echocardiography. The surgical approach was from the right atrium via an atrial septotomy, and the mitral valve was replaced. After separation from cardiopulmonary bypass, a strong reflector accompanied by distal acoustic shadowing was seen inside the left atrium (LA), in the mid-esophageal bicaval view at different degrees of rotation (see video clip at www.anesthesia-analgesia.org.). Migration of the PAC into the LA via the atrial septotomy was excluded, based on the fact that central venous and pulmonary artery pressure waveforms were transduced from the proximal and distal PAC ports, respectively. We considered that one of the permanent pm leads was apparently trapped inside the LA. However, the surgeon was adamant that this had not occurred, and the chest was closed. Further transesophageal echocardiography examination, using similar acoustic windows, failed to reproduce the artifact (Fig. 1). A postoperative portable chest radiograph verified that both permanent pm leads were anchored properly at the right atrium and right ventricular apex.Figure 1.: Modified, mid-esophageal bicaval view after chest closure. A, The left atrium (LA) is at the top of the image. Inside the right atrium (RA), a prominent Eustachian valve is seen to the left, close to the junction with the inferior vena cava (IVC), below the interatrial septum (IAS). One of the pacemaker leads (PM1) is visible. B, With further rotation to 92°, the second pacemaker lead (PM2) is visualized inside the RA.Apart from the main beam, ultrasound transducers emit secondary beams, or side lobes, propagating radially from the center of the main beam (Fig. 2). A returning echo produced by a target located in the side lobes will be displayed as if it originated inside the main beam. The ultrasound energy in the side lobes is considerably weaker than in the main beam; therefore, reflections become apparent only when they do not conflict with real, more intense echoes (1). Examples are an enlarged cardiac chamber, as in the case of a dilated aorta, when the atrial-aortic interface creates a reverberation artifact mimicking a dissection flap, (2) and/or a relatively strong reflector, such as a catheter or a wire (3). To reduce such artifacts, the gain settings should be minimized so that strong reflections from weaker lobes are decreased. If they persist, the echocardiographer may be able to differentiate an artifact from a real structure by imaging the same structure from another acoustic window. An artifact is not likely to be reproduced in multiple echocardiographic planes.Figure 2.: Main and side lobes of the ultrasound beam produced by a phased array transducer. The shadowed cylinder represents the main beam, and the surrounding truncated cone and arrows the side lobes.Shadowing is the absence of echoes behind a highly reflective target, such as mechanical devices (catheters, prostheses) or heavily calcified native structures. When shadowing occurs, an alternate acoustic window is required to view the objects or areas of interest (3). Closure of the atrial septotomy might have altered the relative position between the interatrial septum and the pm lead. As a result, part of the latter (a strong reflector), was reflected by the side lobe, off the center of the ultrasound beam. Approximation of the sternum and the influence of the ventilated lungs may have affected the size of the LA, possibly realigning the pm lead with the main beam of the ultrasound, thus “returning” the image in its true anatomic location, inside the right atrium.

Aortic regurgitation and Churg-Strauss syndrome

Sir, A 56-year-old lady who was a lifelong non-smoker was admitted with acute pulmonary oedema. Echocardiography revealed severe aortic valve regurgitation and a left ventricular ejection fraction of 35–40% associated with moderate left ventricular dysfunction. Coronary angiography confirmed aortic regurgitation, as well as 60% stenosis in the left anterior descending artery with diffuse disease of the distal vessel. Three years earlier, she had been diagnosed with systemic hypertension and was prescribed an angiotensin-converting-enzyme inhibitor. Two months prior to this admission, she was admitted acutely with left ventricular failure and complete heart block, successfully managed with diuretics and insertion of a dual chamber permanent pacemaker. A clinical diagnosis of Churg-Strauss syndrome had been made 20 years …