Male Pilot Research Articles

A young military pilot presents with a periocular Basal Cell Carcinoma: A case report

Basal Cell Carcinoma (BCC) is the most common form of skin malignancy in the UK with 75, 000 new cases per year. It commonly presents as a non-healing lesion in the H zone of the face. The significant risk factors for this condition include UV radiation exposure and a history of sunburn. The gold standard treatment for BCC is Mohs Micrographic Surgery as well a variety of traditional surgical and non-surgical options. A 32 year old white male military helicopter pilot presented with a pea sized lesion which appeared highly vascularised with multiple telangiectasia on the surface. The main risk factors were regular foreign travel to regions of high UV radiation and previous episodes of sunburn. BCC is the commonest form of eye lid malignancy and any form of non-healing lesion on the periocular area should be investigated as a possible neoplasm. The main risk factors are travel to areas of high UV radiation and exposure to UV radiation as a child. There is also a possible risk factor of occupational exposure to ionising radiation from cosmic sources although there is limited research to support this. This is an interesting case of an unusual first presentation of a BCC in a male under 40 years of age and demonstrates the important risk factors in a military population for developing a non-melanoma skin cancer.

Tongkat Ali as a Potential Herbal Supplement for Physically Active Male and Female Seniors—A Pilot Study

Tongkat Ali (Eurycoma longifolia; TA) is known to increase testosterone levels and alleviate aging males' symptoms. This study aimed at investigating TA as an ergogenic supplement for elderly people. Thirteen physically active male and 12 physically active female seniors (57-72 years) were supplemented with 400-mg TA extract daily for 5 weeks. Standard hematological parameters were taken. In addition, the concentrations of total and free testosterone, dihydroepiandrosterone, cortisol, insulin-like growth factor-1, and sex hormone-binding globulin were analyzed. As additional biochemical parameters, blood urea nitrogen and creatine kinase as parameters of kidney function and muscle damage, respectively, as well as the muscle strength by a simple handgrip test were determined. After treatment, hemoglobin, testosterone, and dihydroepiandrosterone concentrations, and the ratio of total testosterone/cortisol and muscle force remained significantly lower in female seniors than in male seniors. Hematocrit and erythrocyte count in male seniors increased slightly but were significantly higher than in female seniors. Treatment resulted in significant increases in total and free testosterone concentrations and muscular force in men and women. The increase in free testosterone in women is thought to be due to the significant decline in sex hormone-binding globulin concentrations. The study affirms the ergogenic benefit of TA through enhanced muscle strength.

Synchronous Rectal and Gastric Cancer in a Fighter Pilot: Aeromedical Concerns

Synchronous cancer of the stomach and rectum is very rare. In a special population of pilots, especially fighter pilots, synchronous rectal and gastric cancer is much more uncommon. We herein report a case of synchronous carcinoma of the rectum and stomach. The patient was a 44-year-old male fighter pilot who complained with bloody stool and altered bowel habits. He was diagnosed with hereditary nonpolyposis colorectal cancer with a definite family history, and subsequently he underwent simultaneous low anterior resection and distal gastrectomy with D2 lymphadenectomy. Postoperative pathologic assessment showed a poorly differentiated gastric adenocarcinoma with signet ring cell components (pT2N1M0; stage IIb) and a moderately differentiated rectal adenocarcinoma with myxoid components (pT3N0M0; stage IIa). Both tumors showed positive expression of p53, Ki-67, VEGF, carcinoembryonic antigen, MRP, TS, P-gp, and TopoII, and negative expression of c-erbB2, CD34, CD31, D2-40, S-100, FVIII, MLH1, MSH2, and MSH6 oncoproteins. Six cycles of XELOX chemotherapy and 50Gy/25f radiotherapy were delivered postoperatively. Now, he has returned to his work under medical observation for about 6months. From this patient's diagnosis and treatment, we think that the gene screening should be used in pilot selection. According to the result of gene screening, we can give pertinence examinations to the target organ of genes. It is very necessary for pilots to keep keen vigilance at gastrointestinal tumors because they have to face many high-risk factors in working. As to pilots, the selection of operation should be individualized.

Height and In-Flight Low Back Pain Association Among Military Helicopter Pilots

Low back pain (LBP) among helicopter pilots is a well-recognized problem, with prevalence ranging from 61 to over 80%. Studies indicate association with total flight hour (TFH) exposure and lack of association with height or body mass index (BMI); however, those that have excluded pilots with back injuries unrelated to flying are limited. Surveyed regarding LBP were 1028 U.S. Navy helicopter pilots. Of the 648 (63%) respondents, 83 pilots, or 12.9%, who reported nonflying related back injuries and those without necessary data were excluded, yielding N = 554. Case-control analysis was performed with logistic regression for height, BMI, and TFH on significant LBP (defined as > 30% of each flight) presence versus absence with Chi-square on the median split of each and ANOVA to include airframes. Height was a positive predictor for significant LBP among all subjects (OR: 1.7), with the strongest association among male pilots (OR: 2.1). BMI, THF, and airframe (H-60, TH-57, H-53, and H-46) were not associated. These results imply that ergonomic stressors that adversely impact lumbar symmetry may be a predominant factor in LBP during flight. Significant prevalence rates may persist in the absence of design enhancements that mitigate these stressors. Height was a significant predictor for in-flight LBP among U.S. Navy helicopter pilots studied and BMI, TFHs, and airframe were not. For every 1" increase among male pilot height values, the odds of experiencing significant LBP in flight increased by 9.3%, with those equal/taller than median (71 in.) having over twice the odds compared with those shorter.

Latent Epilepsy in Pilots: Two Case Reports

Although epilepsy is rare in aviation personnel, 2 long-term duty pilots were discovered to have latent epilepsy. The first case presented is that of a 36-year-old male pilot, with 16 years' flight time, and the second case describes a 30-year-old male Black Hawk pilot with 11 years' duty time. Both reportedly experienced a sudden onset of tonic and clonic convulsions after they had been exposed to stressful conditions. Both of their clinical presentations were consistent with grand mal epilepsy, and their electroencephalogram (EEG) findings were consistent with epilepsy. Both were subsequently suspended from flying duties. An EEG has since been added as part of the pilot selection medical examination in the Royal Jordanian Air Force Medical Services.

Atrial Fibrillation in Two Jet Pilots During Aircrew Periodical Medical Examination

Atrial fibrillation (AF) unfavorably affects cardiac output and may cause acute incapacitation in flight due to loss of the atrial systole, which mainly contributes to the diastolic filling of the ventricles. Although it is the most common type of arrhythmia, it is rare in pilots and not compatible with aviation. We present two AF cases incidentally detected in two jet pilots. The first case was a 39-yr-old male jet pilot with a lone AF. Since there was no structural abnormality or thrombus in the left atrial appendage on transesophageal echocardiography (TEE), the patient was converted to sinus rhythm via direct current cardioversion (DCC). The pilot returned to flying duties after a follow-up period without any recurrent arrhythmia. The second case was a 23-yr-old male jet pilot who had suffered six attacks of paroxysmal AF. Conversion to sinus rhythm was provided by DCC at once and the second via pharmacological cardioversion. Also, spontaneous conversion to sinus was observed during two attacks of AF during the follow-up period. There were no abnormalities on physical examination, echocardiography, and laboratory tests. Although the cardiac ablation procedure was applied, the patient couldn't be treated successfully. Thereafter the pilot was treated with sotalol and warfarin and was permanently disqualified from flying duties. Arrhythmia is among the frequent causes for aviators to be disqualified from flying duties. AF particularly should not be overlooked due to its potential for sudden incapacitation during flight via acute hypotension or thromboembolic events.

The application of nursing model with grouping responsibility system in the psychiatric wards

Objective To explore the implementation effect of nursing model with grouping responsibility system in the psychiatric wards.Methods Patients in male and female pilot wards of quality nursing care demonstration project were practised nursing model with grouping responsibility system.Before and after one year's practice,120 patients (by halves as sex) were randomly sampled to compare nursing satisfaction.After practice,doctors and nurses were investigated to measure satisfaction about implementation of grouping responsibility system.Results After one year' s practice,the nursing care satisfaction rates of two pilot wards patients showed significantly higher than that before practice( P＜ 0.05 ).The total satisfaction rate was 93.2％ in nurse,and 95.8％ in doctor.Conclusions Grouping responsibility system nursing care services for patients with mental illness can close nurse-patient relationship,enhance patient nursing compliance,promote patients mental recovery,raise nurse nursing level,multiple qualifications,and set up a better image of the hospital. Key words: Psychiatric department; Grouping responsibility system nursing; Nursing effect

ECG Screening of Special Populations

Scenario: At 35 years old, all commercial pilots are required by the Federal Aviation Administration to have an annual exam. Specifically, pilots must have a baseline electrocardiogram (ECG) at 35 and then an annual ECG after 40 years of age. You are scheduled on a flight to Reno, Nevada and this is your 52-year-old male pilot’s resting 12-lead ECG. Are you worried? A regular feature of the American Journal of Critical Care, the ECG Puzzler addresses electrocardiogram (ECG) interpretation for clinical practice. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature.

The Annual Incapacitation Rate of Commercial Pilots

Scant data are available on the annual incapacitation rate of aircrew. This study analyzes all incapacitations occurring among UK commercial pilots, in flight and off duty, in 2004 to derive a baseline minimum annual incapacitation rate for the UK commercial pilot population. The study cohort was all professional pilots holding a valid UK/JAR (Joint Aviation Requirements) Class 1 medical certificate and license in 2004. Three data sources were used to identify episodes of incapacitation: the statutory notification of prolonged illness, personal injury, or pregnancy to the UK Civil Aviation Authority; Mandatory Occurrence Reports (MORs) for in-flight medical incidents; and death certificates. The total number of incapacitations was expressed as a proportion of the number of professional pilots to give an incapacitation rate. In 2004 there were 16,145 UK/JAR professional pilot license holders. Of the notified medical events, 36 presented as incapacitations; half were cardiac or cerebrovascular. In-flight incapacitations were predominantly of psychiatric cause. There were four sudden deaths. The type of incapacitation varied with age. A male pilot in his 60s had 5 times the risk of incapacitation of a male pilot in his 40s. The annual incapacitation rate was 40/16,145 = 0.25%. Aeromedical emphasis on minimizing cardiovascular risk and monitoring the mental health of pilots remains appropriate. Age should influence the content and periodicity of regulatory aeromedical assessments. The demonstrated annual incapacitation rate of 0.25% may provide a basis for quantifying the acceptable risk for a pilot undertaking single pilot commercial air transport operations.

Effect of Functional Training on Physical Fitness Components on College Male Students-A Pilot Study

Introduction: Functional Training is how much certain movement will transfer into the actual activity of sport; it’s a matter of neural complexity and central nervous system demand. The aim of this study was to find out the effects of functional training on physical fitness components on college male students. Procedure: 19 male students from the Dr. Meghnad Saha College of the Gour Banga University, were randomly selected as subjects and their age were 19-25 years served as Functional Training Exercises, its three days per week for the period of eight weeks functional training exercises were given for experiments of a single group design. The functional training exercises was conducted in Ladder Forward & Sideward, Medicine ball throw Overhead-2kg, 3kg & 4kg, Hamstrings/Leg Curl With Stability Ball, Lateral Step Ups, Side Punk/Four Point Stabilizations Series, Forward Step Ups, Modified Pull-Up, Foot elevated hip lifting with medicine ball, Press Up with Stability Ball, Medicine Ball Throw Sideward Direction-4kg, 3kg and 2kg etc. before functional training exercises the functional warming up was to applied for tuning up the all body parts. The selected subjects were measured of their physical fitness components, speed, endurance, muscular endurance, strength, explosive power, agility and flexibility. Descriptive statistics was calculation for statistical treatment. Finding: The functional training exercises significantly increase speed, endurance, muscular endurance, strength, explosive power, flexibility and agility. Conclusion: The functional training has significantly improved speed, endurance, muscular endurance, strength, explosive power, flexibility and agility.

A dramatic presentation of cardiac sarcoidosis

A 40-year-old male pilot presented to the emergency department of his local hospital after experiencing palpitations. His symptoms had started 6 h earlier, while playing cricket for the village team. He reported feeling generally unwell and lightheaded, but denied chest pain or breathlessness. He had no chronic medical problems, was a non-smoker, denied recreational drug use and had no family history of cardiac disease. On assessment, he was found to be cool and clammy with a heart rate of 200/min and a blood pressure of 88/60 mmHg. Examination of his cardiovascular system was normal, but there were bibasal crepitations at his lung bases. The initial electrocardiogram (ECG) revealed a broad complex tachycardia, felt to be ventricular in origin and he was promptly electrically cardioverted …

Audiogram of a formerly stranded long-finned pilot whale (Globicephala melas) measured using auditory evoked potentials

Long-finned pilot whales are highly social odontocetes found in temperate and subpolar regions. This species is particularly known for its interaction with fisheries as well as its mass strandings. Recent tagging work has provided some information about pilot whales in the wild but, even though they have been successfully kept in captivity, little is known about their sensory capabilities. This study investigates the hearing abilities of a rehabilitated 2 year old male long-finned pilot whale. A complete audiogram was collected using auditory evoked potential techniques that included measurements of nine frequencies from 4 to 100 kHz presented as sinusoidally amplitude-modulated tones. The results indicated that the region of best hearing was between 11.2 and 50 kHz and the subject had relatively poor high frequency hearing compared with other odontocete species. This study emphasizes the importance of collecting basic hearing measurements from new species, understanding diagnostic life histories as well as continuously increasing the sample size of audiometry measurements within and between odontocete species as animals become available.

Fracture of the Greater Tuberosity of the Humerus

The patient was a 27-year-old male pilot referred to a physical therapist for a suspected left acromioclavicular joint injury following a fall 3 weeks prior. Physical examination revealed decreased active shoulder flexion, decreased supraspinatus strength, and a positive Hawkins test. Radiographs were ordered and the anterior-posterior radiographic view showed an incomplete nondisplaced fracture in the superior aspect of the greater tuberosity. The patient was placed in a sling for 4 weeks and performed passive range-of-motion exercises to maintain shoulder mobility. Radiographs at 7 weeks following the injury revealed a healed greater tuberosity fracture. J Orthop Sports Phys Ther 2010;40(7):447. doi:10.2519/jospt.2010.0411

Ventricular Fibrillation Diagnosed During Electrophysiological Study for Non-Sustained Tachycardia

Ventricular fibrillation diagnoses such as Brugada syndrome pose a risk of sudden incapacitation or death in aircrew. This case report presents a 44-yr-old male fighter pilot who unexpectedly developed ventricular fibrillation (VF) during an electrophysiological study (EPS) prior to therapy for non-sustained ventricular tachycardia (nsVT). The initial aeromedical disposition for this case was "qualified for flying duties". with the restriction that he must fly with another pilot due to repeatedly observed nsVT. This pilot wanted to return to flight duty in single-seat aircraft without any restrictions. Therefore, this patient decided to undergo catheter therapy for nsVT. Unexpectedly, not VT but VF was induced by catheter manipulation during EPS. Pilsicainide-induced coved-type ST wave elevation consistent with Brugada syndrome was noted in this patient's electrocardiogram. He was ultimately disqualified due to the diagnosis of VF. This report suggests EPS on rare occasions may uncover another severe disease similar to this case report.

Neurologic Decompression Sickness Following Cabin Pressure Fluctuations at High Altitude

Decompression sickness (DCS) occurs in diving, altitude chamber exposures, and unpressurized or depressurized high-altitude flights. Because DCS takes many forms, in-flight cases may be misinterpreted as hypoxia, hyperventilation, or viral illness, with resulting failure to respond appropriately. In this case, a 28-yr-old male pilot of a single-seat, tactical aircraft experienced 12 rapid pressure fluctuations while flying at 43,000 ft above sea level. He had no symptoms and decided to complete the flight, which required an additional 2 h in the air. Approximately 1 h later he began to experience fatigue, lightheadedness, and confusion, which he interpreted as onset of a viral illness. However, symptoms progressed to visual, cognitive, motor, and sensory degradations and it was with some difficulty that he landed safely at his destination. Neurologic DCS was suspected on initial evaluation by flight line medical personnel because of the delayed onset and symptom progression. He was transferred to a local Emergency Department and noted to have altered mental status, asymmetric motor deficits, and non-dermatomal paresthesias of the upper and lower extremities. Approximately 3.5 h after the incident and 2.5 h after the onset of symptoms he began hyperbaric oxygen therapy. He received partial relief at 30 min of the Navy DiveTable 6 and full resolution at 90 min; there were no recurrent symptoms at a 1-yr follow-up. This case highlights the importance of early recognition of in-flight DCS symptoms and landing as soon as possible rather than as soon as practical in all likely scenarios.

Sacral Meningocele in a Military Pilot, Presenting During Flight

This study describes an unusual case of a military pilot with sacral meningocele that contained cerebrospinal fluid and presented as episodes of gluteal neuralgia during flight. The patient, a 38-yr-old male pilot, had complained of a dull and mild low lumbar pain over the previous 10 mo. These pains were exacerbated and radiated to the left gluteal region during flight. The patient's history, clinical examination, imaging findings, and treatment are reported. CT and MRI imaging revealed an unusual case of sacral meningocele (2.2 cm x 3.6 cm X 5.8 cm). These lesions can progress steadily in size, leading to worsening symptoms and potentially requiring surgical management. However, surgery is not indicated for stable and asymptomatic lesions not associated with tumors. In our case, tactical monitoring was suggested, since no other symptoms appeared. There are currently no other reported cases involving pilots, so an individual approach to treatment should be taken in accordance with their military health service, the potential, risk factors, and depending on the level of acceleration experienced. We discuss the pathogenesis, the clinical and radiological findings of this rare condition, and note that a spinal cyst is of special interest when occurring in pilots since they are exposed to intense accelerations and spinal strain.

Fly Girls: The WWII Women’s Airforce Service Pilots (review)

Reviewed by: Fly Girls: The WWII Women’s Airforce Service Pilots Wallace Lewis Fly Girls: The WWII Women’s Airforce Service Pilots (1999). Written, Produced, and Directed by Laurel Ladevich Silverlining. Productions for WGBH and the American Experience. www.wgbh.org, 56 minutes. During World War Two, the Women’s Airforce Service Pilots (WASP) ferried military aircraft around the U.S., trained male pilots, towed targets for anti-aircraft gunnery practice, and flight-tested aircraft. More than a thousand women flew for the WASP, and thirty-eight died while doing so. Yet they had civilian—not military—status, and their contributions and sacrifices were long obscured from public memory. The documentary film Fly Girls, which appeared on PBS television in 1999, lifts some of that obscurity. Woven together with the story of Jacqueline Cochran’s struggle to form and command the WASP are personal experiences related by six of its surviving veterans. Cochran, the one-time beautician who had reinvented herself as a world class racing pilot, was able to establish rapport with General H. “Hap” Arnold, chief of the Army Air Forces. Arnold ordered a competing plane ferrying service to merge with Cochran’s group and train at Avenger Field in Sweetwater, Texas. Following successful graduation at “Cochran’s Convent,” as the airfield became commonly known (she soon forbade “emergency” landings at the all-woman base by male pilots), the women received their silver wings and were assigned to various Army Air Corps bases. The WASP pilots put in long hours in the air, often not knowing when or where a particular task would end. Once, expecting a one-day trip, Teresa James recounts that she was gone for a month without a change of clothing. Male pilots were often hostile to their female counterparts, and men sometimes would not ground planes that needed maintenance if they knew that women would be flying them. Investigating a series of engine failures and two fatalities at Camp Davis, North Carolina, Jackie Cochran discovered sugar in one fuel tank. But she declined to force an official investigation because she feared it would threaten her program. And there were accidents. One woman burned to death in a crash landing. Cornelia Fort was killed when a male pilot accidentally clipped the wing of her aircraft. Often, antiaircraft fire came dangerously close to—or actually hit—planes in which the women were towing targets, resulting in one fatality. Of the WASP veterans who spoke on camera, Ann Baumgartner perhaps pushed the envelope furthest. She served as a test pilot at Wright Field in Dayton, Ohio, flying the first U.S. experimental jet fighter—the Bell WP59A—in 1943. Another, Dora Daugherty, learned to fly the B-29 Superfortress bomber and then trained men to operate the aircraft. At the time, the B-29 had a bad reputation for safety among bomber pilots, many of whom feared flying it. On her first training flight in a B-29, Daugherty had taken control of the plane from her instructor, Paul Tibbetts (who would command the Enola Gay and drop the first atomic bomb on Hiroshima), when she was confronted with the loss of one engine and smoke in the cockpit. She coolly followed procedure to resolve the situation. When it became apparent that women could operate the aircraft with little trouble, the egos of male pilots responded—just as Tibbetts had hoped. Militarizing the WASP became an issue in 1944. Hap Arnold wanted to make it part of the Women’s Army Corps (WACs), but Cochran feared that such a move would ground her pilots and make her subordinate to the WAC commander. She lobbied General Arnold to push for a separate military WASP unit. However, the timing was bad. Many Army pilots faced retraining as combat ground soldiers, since demand for their flying was declining late in the war. Ferrying aircraft gave them a chance to avoid that fate. In addition, public opinion about many of the roles women filled in the war effort was beginning to swing away from admiration to condemnation. By the fall of 1944 it was widely considered to be unpatriotic for a woman to do a man’s job. When, [End...

Brugada Syndrome in an Active Duty Air Force Senior Pilot

Brugada syndrome describes a subgroup of patients at risk for polymorphic ventricular tachycardia, ventricular fibrillation, and sudden cardiac death and is likely underdiagnosed among aviators. A 40-year-old male pilot presented to the clinic for his physical. He denied any symptoms on initial questioning. Subsequent electrocardiogram (ECG) revealed premature ventricular couplets with ST-segment elevation in V1 and V2 of the precordial leads with T-wave abnormalities. Special care must be taken if ECG demonstrates a Brugada pattern-especially in patients with a history of syncope or a family history of sudden death. Recent studies have confirmed a significant risk reduction in symptomatic patients with type 1 Brugada to as low as 0.8% to 3% with an implantable cardioverter defibrillator. Symptomatic patients displaying type 1 Brugada ECG (spontaneous or after sodium channel blockade) should receive an implantable cardioverter defibrillator and must be permanently disqualified. The Aeromedical Consultation Service should review all cases of Brugada syndrome and render a return to fly for asymptomatic nondiagnostic Brugada types.

Spontaneous Pneumothorax in Flight as First Manifestation of Alpha-1 Antitrypsin Deficiency

Alpha-1 antitrypsin deficiency is a genetic condition that increases the risk of a variety of conditions including pulmonary emphysema and chronic liver disease. We report on a 33-yr-old male fighter pilot with early-onset pulmonary emphysema with bullae who developed spontaneous pneumothorax during in-flight combat training. A CT scan of his chest after removal of the chest tube showed multiple variably sized bullae and pulmonary cysts scattered throughout both lungs. Serum levels of alpha-1 antitrypsin were markedly decreased. Genetic analyses showed a PI ZZ genotype. Alpha-1 antitrypsin deficiency often goes undiagnosed by flight surgeons, which is a risk to flight safety.

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)