Author’s Accepted Manuscript An unusual chest radiograph in a patient with implantable cardioverter defibrillator: How was this device implanted? Aditya Saini, Kenneth A. Ellenbogen www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S2214-0271(16)30153-1 http://dx.doi.org/10.1016/j.hrcr.2016.12.006 HRCR327
To appear in: HeartRhythm Case Reports Cite this article as: Aditya Saini and Kenneth A. Ellenbogen, An unusual chest radiograph in a patient with implantable cardioverter defibrillator: How was this device implanted?, HeartRhythm Case Reports, http://dx.doi.org/10.1016/j.hrcr.2016.12.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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An unusual chest radiograph in a patient with implantable cardioverter defibrillator: How was this device implanted? Aditya Saini, MD; Kenneth A. Ellenbogen, MD FHRS Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA Author Contacts: Aditya Saini , Kenneth A. Ellenbogen Virginia Commonwealth University Medical Center P.O. Box 980053 Richmond, VA 23298-0053 Phone : 804-828-7565 Fax : 804-828-6082 E-mail:
[email protected] [email protected]
Disclosure: Relative to this image, authors have no conflicts of interest.
Key Teaching Points
1. To illustrate the importance of chest X ray as a key imaging tool for cardiac electrophysiologists and health care practitioners taking care of patients with defibrillators. 2. To recognize unusual device implantation techniques through chest X ray analysis and be able to put into correct clinical context in deciding the appropriate next step in patient management. 3. To recognize the significance of correct positioning of the ICD lead to maximize success of defibrillation by ensuring an appropriate shock vector.
2 A 74 year old woman with chronic systolic heart failure, recurrent syncope with inducible sustained monomorphic ventricular tachycardia underwent implantation of single chamber implantable cardioverter defibrillator (ICD) in 2004. She had a history of breast cancer treated remotely with mastectomy, axillary lymph node dissection, radiation and chemotherapy. Her chest radiograph with posteroanterior (PA) and lateral views is shown in figure 1. How was this device implanted?
The PA view (left panel) demonstrates an unusual course of the dual coil defibrillator lead and an inferiorly located device generator (left panel- arrowhead). The lateral view is required to further define the course of the ICD lead. This is better shown in the right panel of the figure. The lead terminates in the right ventricle (RV) and it appears to be in the RV apex and while the distal coil (DC) is intracardiac, the proximal coil (PC) does not appear to be intracardiac or intravascular. In fact, the lead does not appear to be entering the heart via the superior vena cava but seems to be penetrating the cardiac silhouette directly at the level of the anterior right atrium. Another important observation is that the proximal coil is outside the cardiac silhouette and appears to be in the subcutaneous or submuscular layer of the chest wall. In addition, multiple surgical clips from prior chest surgery are noted in right lateral chest wall and axilla while a couple of surgical clips are also seen on right anterior chest. Our review of records from the outside hospital where it was implanted indicated that the patient had an unsuccessful attempt at implantation of a transvenous ICD system due to inaccessible and occluded central veins related to prior radiation therapy and chest surgery. The device was implanted surgically via a right anterior thoracotomy at level of the third costal cartilage. The right pleural cavity was entered after excision of a segment of the 3rd rib. Pericardiotomy was performed and the right atrium was accessed through the appendage followed by implantation of a 58 cm dual coil ICD lead in the RV apex delivered through an 11 Fr introducer sheath. The lead was secured at the right atrial appendage insertion site by pursestring sutures and was then tunneled submuscularly over to the ICD generator which in turn was implanted in a subfascial pocket in the left lower chest.
3 What issues are expected with device functioning in this patient? The right ventricle is an anterior cardiac structure and optimum defibrillator lead positioning to achieve an appropriate shock vector for successful defibrillation is critical. The major concern with this implant is the inferiorly located pulse generator and the fact that the proximal coil is in subcutaneous tissue in the anterior chest rather than a more posterior location. Although sensing of VT/VF should be normal since the RV lead tip is in an appropriate position but there is a possibility of unsuccessful defibrillation. A subcutaneous ICD would be an ideal device for this patient in current times. All lead parameters tested within normal limits in this patient. This patient had no DFT testing at time of surgical implantation, however DFT testing was performed at time of a subsequent generator change in 2012 and VF was successfully detected and treated by the ICD.
