Int J Clin Exp Med 2015;8(8):14472-14478www.ijcem.com /ISSN:1940-5901/IJCEM0010799

Case ReportRetaining of PTCA guide wire in the left ventricular lead and subsequent application of epicardial electrode when CRT-D implantation in a patient with severe heart failure and persistent left superior vena cava: a case report

Pei-Pei Hou, Yu-Hong Liu, Hai-Bo Qu, Jin Meng, Qiang Li, Zhi-Lin Miao

Heart Center, The People’s Hospital of Liaoning Province, Shenyang 110016, P. R. China

Received May 28, 2015; Accepted July 20, 2015; Epub August 15, 2015; Published August 30, 2015

Abstract: Objective: One patient with severe heart failure (LV 92 mm, EF 28%) was treated by cardiac resynchroniza-tion therapy (CRT). Method: During the operation, it was found that double superior vena cava coexisted, and selec-tive coronary venography cannot clearly show every branch. It was difficult to push ventriculus sinister electrode to sideward vein, so the electrode was released to far end of frontal septal branch along great cardiac vein. Result: However, because of insufficient braced force of ventriculus sinister electrode, 0.014 PTCA guide wire was detained in the electrode. 2 years later, two spots of PTCA guide wire retained in ventriculus sinister electrode broke in atrium dextrum, so the implantation of epicardial electrode was conducted. Conclusion: After the operation, heart failure was relieved. After 43 months, the battery of pacemaker depleted, so the pacemaker was changed. The effect since follow-up visit was good, LV decreased to 86 mm, EF increased to 32%, and SPWMD time limit shortened from 147 ms to 45 ms. The therapeutic experience of this patient indicated that the effect of detaining PTCA guide wire to enhance braced force in implantation of ventriculus sinister is unreliable and inappropriate to be advocated.

Keywords: Cardiac resynchronization therapy, persistent left superior vena cava, PTCA guide wire, epicardial left ventricular lead

Case report

The 46-year male patient was admitted to the hospital on January 18th, 2011 for complaints of palpitation, hard breath for 4 months, and paroxysmal nocturnal dyspnea for one week. In recent 4 months, the patient showed flustered and hard breath after activity. He was diag-nosed as “dilated cardiomyopathy and conges-tive heart-failure” by other hospital. His symp-toms did not turn significantly better after tak-ing inotropic support and diuretic therapy. In recent one week, hard breath exacerbated sig-nificantly accompanying with paroxysmal noc-turnal dyspnea and inability of prostration. Physical examination: blood pressure: 90/70 mmHg, conscious mind, and sitting position; bubbling sound could be heard at the bottom of both lungs; heart border expanded to the left, heart rate 98 times/min, regular heartbeat,

and 3/6 level systolic murmur could be heard in apex of heart; liver enlarged to 3 cm lower of rib; both lower extremities showed mild pitting edema. The electrocardiogram showed sinus rhythm, complete left bundle branch block, and 197 ms of QRS wave width (Figure 1). Cardiac ultrasound showed LA 50 mm, LV 92 mm, and EF 28%; medium dose of regurgitation in valvu-la bicuspidalis and a little hydropericardium; 147 ms of septal to posterior wall motion delay (SPWMD), 229 ms of aortic pre-ejection interval (APEI), and 117 ms interventricular mechanical delay (IVMD). The cardiothoracic ratio in rabat was 0.81 (Figure 2). Dynamic electrocardio-gram showed sinus rhythm, 95 times/min of average heart rate, 771 times of ventricular pre-mature beat (VPB), one pair of ventricular cou-plet, and a burst of nonsustained ventricular tachycardia (continuous 8 ventricular beats). The patient walked 105 m in 6-minute walk

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test. Coronary arteriography on January 22nd, 2011 showed that the distal segment in left anterior descending branch of coronary artery narrowed by 60%. Diagnosis: dilated cardiomy-opathy, whole heart failure, level IV cardio func-tion, and arrhythmia (complete left bundle branch block, frequent ventricular beat, and nonsustained ventricular tachycardia). All these symptoms of this patient satisfied with adapta-tion of class I for CRT-D in 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm [1]

to send 0.14 PTCA guide wire (Rinato, ASAHI INTECC CO., LTD., Japan) to sideward vein and send Medtronic 4193 along guide wire, so elec-trode was sent to the far end of frontal septal fasciculus along great cardiac vein. Left anteri-or oblique showed that the pace-making posi-tion was located on lateral wall of left ventricle, pacing threshold for test was 0.7 V, impedance was 846 Ω, R wave amplitude was 18 mv, and no diaphragm beat in 10 V pace-making. Medtronic 6944 defibrillation electrode was

Figure 1. Electrocardiogram in admission (January 18th, 2011).

Figure 2. DR diagram of chest PA in admission (January 18th, 2011).

issued by ACC/AHA/HRS in May 2008. Therefore, treat-ment of cardiac effect, diure-sis, and vascular dilation was given, and it was suggested to take implantation of CRT-D.

After successfully conducting left subclavian venipuncture on January 24th, 2011, it was found as persistent left supe-rior vena cava (PLSVC) when sending guide wire. Then, after successfully conducting right subclavian venipuncture, it was found as double superior vena cava (DSVC) (Figure 3). It was difficult to conduct se- lective coronary venography along right subclavian vein, and all branches cannot be clearly shown. It was difficult

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sent to right ventricular apex along right subcla-vian vein, Medtronic 5076 electrode to the auricular appendix of atrium dextrum. When testing biventricular pacing, QRS wave nar-rowed. When removing the long sheath and guide wire of left ventricular electrode, the elec-trode dislocated repeatedly for the insufficient braced force of left ventricular electrode. At that time, the patient refused to take implanta-tion of epicardial electrode, so 0.014 PTCA guide wire was retained in left ventricular elec-

maker (Figure 5). During AV extension, QRS download diagram occurred. Under X ray, two broken spots of 0.014 guide wire retained in left ventricular electrode could be seen in atri-um dextrum, but the electrode did not break. After discussion, it was decided to put the left ventricular electrode aside, and conduct epi-cardial electrode implantation with heart beat-ing under general anesthesia to implant Medtronic epicardial electrode on left ventricu-lar lateral wall. The test parameters were good,

Figure 3. Guide wire sending to atrium dextrum after puncture in left and right subclavian vein.

Figure 4. Two broken spots of guide wire detained in left ventricular elec-trode in atrium dextrum.

trode to fix the electrode and connect with Insync Sentry 7285 pacemaker (Medtronic Inc., U.S.A). After operation, the symp-toms of chest distress and hard breath significantly improved, and the activity tolerance increased. One week after operation, cardiac ultrasound showed LA 45 mm, LV 91 mm, and a little regurgitation of valvula bicuspidalis; EF value increased to 33%; SPWMD short-ened to 47 ms, APEI to 142 ms, and IVMD to 21 ms. The chest radiography showed the podoid shrunk, and pulmonary conges-tion reduced. The patient was not readmitted to the hospital for car-diac failure in half a year after operation.

In January 2012, the pacemaker alerted. Program control showed that the impedance of left ventric-ular electrode was larger than 2500 Ω, and the function of pace-making and perception was nor-mal. The electrode showed no dis-location and fracture under X ray, while the guide wire retained in left ventricular electrode was bro-ken at two spots in atrium dex-trum, which may cause electrode wear at these spots (Figure 4). In October 2012, the patient was readmitted to the hospital for chest distress, hard breath, and inability of prostration. Program control found that the pace-mak-ing function of ventriculus sinister electrode had lost, and the pacing electrocardiogram was the dia-gram of one right ventricle pace-

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and the implant was connected to the original pacemaker through the subcutaneous tunnel (Figure 6). After operation, the symptom of heart failure relieved, and activity tolerance sig-

tion is the implantation of left ventricular elec-trode [3, 4]. Currently, the left ventricular elec-trode is always implanted into the far end of lateral branch [5] in coronary vein to make left

Figure 5. Pace-making electrocardiogram shows only pace-making diagram of atrium dextrum.

Figure 6. The right upper is epicardium electrode, and the lower is the original left ventricular electrode (October 20th, 2012).

nificantly improved. In July 2014, the battery of pacemaker depleted in the examination of conventional follow-up, but the pace-making and perceptive parameters were good. The guide wire in original left ventricular electrode put aside had been broken under X ray (Figure 7). Medtronic Maximo II D284TRK pacemaker was replaced success-fully, and the effect was good until now in follow-up visit. The patient can move 350 m in 6 min walk test, LV decreased to 86 mm, EF maintain at 32%, and SPWMD was 45 ms.

Discussions

With the gradually mature technol-ogy of cardiac resynchronization therapy (CRT), CRT has become an important method of non-medi-cine treatment for patients with cardiac failure in later period at present [2]. The key to CRT opera-

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ventricular pacing. Affected by anatomical structure of precava, vessel arrangement and distribution of coronary vein, and if the arrange-ment is tortuous or not, the implantation of left ventricular pacing is sometimes difficult, and may even cause operation failure.

In this case, the coexistence of persistent left superior vena cava makes CRT implantation quite difficult. According to literature re- ports, normal left superior vena cava gradually closes in embryonic development, and finally imports into coronary sinus [6]. The left superi-or vena cava directly introduced into coronary sinus accounts for 0.5% in normal population [7]. Among these population, 10-15% have right superior vena cava absent. Generally, ret-rograded coronary venography is conducted by blocking off the trunk of coronary vein with cor-onary sinus radiography saccule to obtain a better image of every branch vein [8-10]. In this case, the patient cannot display coronary vein branch by conventional method for the return of left superior vena cava. If special big balloon block the left superior vena cava off, a better image can be obtained. By delay imaging of coronary arteriography, lateral branch of coro-nary vein can be seen. However, 0.014 PTCA guide wire was sent to lateral branch of coro-

was maldeveloped and small). Finally, great cardiac vein branch reached to left ventricular lateral wall. QRS wave group narrowed by biven-tricular pacing, which verifies that this pace-making point is also the delayed part of left ventricular activation. It is remaindered that in CRT iatrotechnics, it should be considered that if the activated pace-making in delayed part can be reached through far end of other ves-sels without good lateral vessel selection to realize the function of free-running biventricu-lar movement.

2. In this case, PTCA guide wire was retained to fix left ventricular electrode because of the bad retention stability of left ventricular electrode and there was no other active electrode. One year later, the left ventricular electrode alerted and impedance increased. Under X ray, the retained guide wire was curved in atrium dex-trum and at the corner of entrance of coronary sinus. Considering that the guide wire wore the electrode, the electrode impedance increased. After 9 months, retained guide wire was broken at the corner under X ray, which may be related to long-term heartbeat. Therefore, the method of retaining guide wire in electrode is unreliable and inappropriate to be advocated. According to the case reports on CRT/CRT-D implantation

Figure 7. The arrow shows the broken spot of electrode lead (August 6th, 2014).

nary vein. Because the branch was small, 4193 left ventricular electrode was abandoned because it cannot enter into far end, and finally, it reached left ventricular lateral wall through great cardiac vein branch. In this case, PTCA guide wire was retained to fix left ventricular electrode because of the bad retention stability of left ven-tricular electrode and there was no other active electrode.

Following lessons are conclud-ed according to this case:

1. Pace-making point of left ventricular electrode should be located in the most delayed part for left ventricular activa-tion (lateral branch of coronary vein). In this case, however, the left ventricular electrode could not enter into the lateral branch of coronary vein smoothly (may be because this branch vein

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in coexisted persistent left superior vena cava, the implant was sent by traffic branch of persis-tent left superior vena cava and precava, or implanted in epicardium electrode cable by tho-racotomy or thoracoscope [11-15]. If 4195 electrode of left ventricle was implanted by PLSVC and connected with the right side through subcutaneous tunnel, the stability of left ventricular electrode can be ensured and the risk brought by retained guide wire can be avoided.

3. The primary way to implant the left ventricu-lar electrode by CRT is to send the implant into cardiac vein branch through coronary vein entry. This method is featured with small trau-ma, independent operation by cardiologists, and high success rate. However, about 2-10% patients cannot take the implantation of left ventricular electrode by vein because of indi-vidual difference of cardiac vein anatomical structure for congenital or acquired factors, including malformation of coronary vein open mouth, valve, obvious angle of target vein, small or absent target vein, instable fixation, high threshold, or diaphragm activation [16-18]. In this case, left ventricular electrode can-not be implanted by intervention after losing pace-making function. Therefore, epicardium electrode implantation was conducted immedi-ately to implant epicardium electrode on side wall of left ventricular sinister to recover the pace-making function of left ventricular elec-trode, correct out-sync motion of left and right ventricle, and improve heart function of patients. In addition, the epicardium electrode guide wire can obtain better haemodynamic effects because the left ventricular electrode can be placed in the latest activation part shown according to ultrasound technology, etc. [19, 20] after thoracotomy. Therefore, epicardi-um electrode should be implanted by surgery when left ventricular electrode cannot be implanted by cardiac vein or reach appropriate pace-making position, or the pace-making parameters are not satisfied.

Disclosure of conflict of interest

None.

Address correspondence to: Zhi-Lin Miao, Heart Center, The People’s Hospital of Liaoning Province, Shenyang 110016, China. Tel: +86-024-24016226; E-mail: zhilinmiaodoc@yeah.net

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