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  • Permanent pacemaker implantation with trans IVC access

    2019-04-15

    Permanent pacemaker implantation with trans-IVC access was first reported in 23 cases by Ellestad et al., in 1980 [2]; it was then reported in 95 cases, of which the early cases were published in 1989 by the same author as the largest series reported thus far [5]. Mathur et al. also reported 27 cases managed using the same method in 2001 [6]. This method may be applicable even in those cases wherein implantation cannot be performed using the conventional method. The cases presented previously include those in which a pouch could not be created in the precordium region because of mastectomy, those in which a lead could not be advanced into the imidazoline because of the occlusion of the subclavian vein [2,5,6], and those in which the patient had pain in a previously created pacemaker pocket [5]. Aortic aneurysm, as shown in the present case, may be an uncommon reason for lead placement via the femoral vein. However, this method has not been generally used in clinical practice due to various disadvantages. First, this method necessitates restriction of leg movement, thereby restricting the daily activities of the patient to a greater extent than that resulting from lead placement with the usual method. Second, lead displacement, especially in the atrium, was reported frequently [2,5–7]. In the cases reported by Ellestad et al., 9 (21%) of 42 atrial leads and 5 (7%) of 67 ventricular leads were reported to have required displacement and revision, respectively [2,5]. Mathur et al. reported that atrial lead displacement occurred in 5 leads (20%), and there were no ventricular lead displacements [6]. Although the reason for the lead displacement is unclear, various factors may have been responsible: the long distance from the puncture point to the heart, difficulty in the manipulation of the lead from the femoral vein, and weak immobilization of the distal lead on the puncture point, among others. In the atrium particularly, fixation in the myocardium is weak due to its anatomical structure. Although rare, bleeding from leakage at the point of entry into the femoral vein [2], phlebitis due to the lead [2,5,8], and persistent pain [6] have also been reported. Lead fracturing and deep venous thrombosis are also possible complications of this method, but have not been reported by some studies [2,5,6]. We used only 1 ventricular lead in this case, but made every possible attempt to overcome the problems associated with lead displacement. For example, we used a long active fixation lead sufficient to reach from the femoral area to the heart, as is generally recommended [2,5–7]. Because of the length of the lead, we could manipulate it easily and the entire lead could enter the vessel. Additionally, we punctured the inguinal ligament to enter the femoral vein, sutured and fixed a sleeve device on the ligament, and immobilized the distal lead to prevent its shearing. This technique also helped avoid excessive bleeding. However, since it is not always possible to completely eliminate all the associated problems, full postoperative rest, frequent chest radiography, and monitoring of the pacemaker condition, as well as careful observation of the clinical course are needed.
    Conflict of interest
    Case presentation A 38-year-old female with frequent episodes of palpitation was referred to our hospital for the diagnosis and management of tachycardia. Her annual medical check-ups did not reveal any abnormalities, and she had no history of cardiovascular diseases or medications. Her family history was negative for cardiac events and sudden death. No obvious structural heart disease was detected during physical examination, resting electrocardiography, chest radiography, or echocardiography. She generally had palpitations during exercise and when she was under emotional stress, and they terminated spontaneously within 2h. Surface 12-lead electrocardiogram (ECG) obtained during a lasting episode of palpitation showed wide QRS complex tachycardia with a right bundle-branch block (BBB) pattern and inferior axis (Fig. 1). This tachycardia transiently developed from sinus tachycardia occurring after psychological stress and disappeared spontaneously, with the restoration of sinus rhythm (Fig. 2). A small dose of ATP temporarily suppressed the tachycardia, which was then completely eliminated after the administration of a 5.0-mg dose of verapamil (Fig. 3).