ARTICLE IN PRESS doi:10.1510/icvts.2010.240507
Interactive CardioVascular and Thoracic Surgery 11 (2010) 366–368 www.icvts.org
Case report - Arrhythmia
Challenging pacemaker implantation in a patient with acquired dextrocardia after pneumonectomy, skoliosis and complete heart block Karsten Hamm*, Dariush Haghi, Martin Borggrefe, Ju ¨rgen Kuschyk First Department of Medicine-Cardiology, Angiology, Pneumology, Intensive Care Medicine, University of Heidelberg, Mannheim, Germany Received 11 April 2010; received in revised form 10 May 2010; accepted 18 May 2010
Abstract Pacemaker implantation after pneumonectomy is rare and there have been no previously reported cases of acquired dextrocardia after implantation. The authors report the case of a pacemaker implantation in a patient with complete heart block, impaired left ventricular function, sclerosis of heart valves and radiation induced vasculopathy resulting in ostial stenosis of the right coronary artery 30 years after radiochemotherapy in childhood. Acquired dextrocardia after right pneumonectomy for mucoepidermoid carcinoma made implantation a challenge due to and poor fluoroscopic visualization of the heart and increased radio-opacity of the right chest when compared to congenital dextrocardia. 䊚 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Pacemaker; Complete heart block; Dextrocardia; Pneumonectomy; Cardiotoxicity; Radiochemotherapy
1. Case report A 40-year-old man, with a history of right-sided pneumonectomy, was referred to our institution because of weakness, dizziness, dyspnea on exertion and pain in the right upper abdomen. At the age of 10, he had a right-sided pneumonectomy for mucoepidermoid carcinoma of the right main bronchus, followed by radiotherapy and high-dose chemotherapy with doxorubicine. He had undergone a subtotal thyroidectomy for goiter seven years previously which was complicated perioperatively by pulmonary edema. A left-bundle branch block (LBBB) had existed since then (Fig. 1, panel a). His past medical history was otherwise unremarkable. His medication was limited to L-thyroxin. On physical examination marked bradycardia (25 bpm), a moderate thoracic skoliosis, pectus carinatum with hypoplasia of the right hemithorax and a rightward displacement of the trachea were evident. His blood pressure was 140y 80 mmHg. A 12-lead-electrocardiogram showed complete heart block with a broad complex ventricular escape rate at 25 bpm, left axis deviation, LBBB morphology and tall R-waves in V1 to V3 (Fig. 1, panel b). A chest X-ray revealed a rightsided pneumonectomy, rightward displacement of the cardiac silhouette and mild pulmonary congestion. Pulmonary function tests demonstrated severe restrictive lung disease *Corresponding author. First Department of Medicine, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany. Tel.: q49 621 3832204; fax: q49 621 3833878. E-mail address:
[email protected] (K. Hamm). 䊚 2010 Published by European Association for Cardio-Thoracic Surgery
with a vital capacity of 2 l (40% of predicted) without signs of obstruction (Tiffenau index of 106%). Apart from an elevated white cell count at 13,000yml, other laboratory findings were within normal range. Echocardiography was only possible through a right parasternal window and demonstrated degenerative calcification of the mitral and aortic valves. Left ventricular function (LVF) was moderately reduced and the left ventricle was slightly dilated (54 mm). The patient underwent coronary angiography which revealed radiation vasculopathy with an ostial stenosis of the right coronary artery. The high-grade stenosis was treated by stent implantation without resolution of the complete heart block. Cardiac magnetic resonance imaging had been performed for evaluation of LVF one year earlier (Fig. 2, panel a and b) and had demonstrated the presence of the heart in the right hemi-thorax. The heart was rotated ;908 along its vertical axis and the major heart axis was aligned from the left shoulder to the right hip. LVF was moderately reduced (ejection fraction 41%). The patient underwent implantation of a dual chamber pacemaker using a left-sided approach. Lead implantation, which was performed under fluoroscopic guidance using anteroposterior (a.p.) and 308 right-anterior-oblique views, turned out to be challenging, as neither the cardiac silhouette nor the heart’s orientation were readily appreciable within the right hemithorax. Lead positions were identified as atrial and ventricular according to measured electrophysiological signal amplitudes. Finally, two active fixation bipolar electrodes were implanted in the right atrium and the right ventricle (Fig. 2, panel c and d). The pacemaker
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Fig. 1. Twelve-lead ECGs (50 mmys; 1 mVycm) (a) seven years ago, (b) at presentation and (c) after pacemaker implantation.
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Fig. 2. (a) Thoracic topography in a magnetic resonance image (coronal plane); (b) thoracic topography in a magnetic resonance image (axial plane); (c) chest X-ray after pacemaker implantation (a.p. projection); (d) chest X-ray after pacemaker implantation (lateral projection). LV, left ventricle; RV, right ventricle; Ao, aorta; PA, pulmonary artery; PV, pulmonary artery; a.p., anteroposterior.
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was implanted underneath the pectoral muscle in this thin patient with pectus carinatum. Sensing and pacing threshold were within normal range. 2. Discussion Dextrocardia is a condition in which the major axis of the heart points to the right. It can be congenital or acquired. Dextrocardia must be distinguished from dextroposition which is defined as the presence of the heart in the right hemi-thorax with normal alignment of the major heart axis. Acquired dextrocardia following right pneumonectomy has been previously reported w1x. There is very limited experience with pacemaker implantation after pneumonectomy and to the best of our knowledge there is no report of pacemaker implantation in acquired dextrocardia. There are isolated reports on pacemaker implantation in congenital dextrocardia w2–4x. In these cases, unlike in acquired dextrocardia after pneumonectomy, fluoroscopic discrimination of the heart itself is very possible and does not add further to the anatomical challenge of lead placement. The unusual topography of the heart makes preoperative visualization of the individual anatomy advisable when the clinical situation allows. In this case fluoroscopy was of limited value. Pacing lead placement was guided by atrial and ventricular electrograms to overcome the described obstacles. Biventricular pacing was considered but not implemented in this patient according to guidelines as he was completely asymptomatic (NYHA I) for years prior to complete heart block. LVF was judged to be moderately reduced and thus prophylactic defibrillator implantation was not justified.
The potentially cardiotoxic effects of radiotherapy and chemotherapeutic agents, such as doxorubicine are well known in adults and children w5, 6x. Potential side effects of radiochemotherapy have to be considered even decades after its application in cardiac disease. In the present case heart block, reduced LVF and ostial stenosis of the right coronary artery are attributed to radiochemotherapy in childhood. 3. Conclusion Pacemaker implantation is challenging in acquired dextrocardia due to increased radio-opacity of the right chest and poor fluoroscopic visualization of the heart when compared to congenital dextrocardia. References w1x Abbas AE, Liu P, Lee RW. Acquired post-pneumonectomy dextrocardia. Interact CardioVasc Thorac Surg 2004;3:25–27. w2x Fang Y, Jiang LC, Chen M. Successful pacemaker implantation in a patient with dextrocardia situs inversus totalis. Europace 2009;11:1568– 1569. w3x Subbiah RN, Gula LJ, Yee R, Skanes AC, Klein GJ, Krahn AD. Images in cardiovascular medicine. Pacemaker implantation in a patient with dextrocardia, corrected transposition, and situs inversus. Circulation 2007;115:e607–e609. w4x Goyal SL, Lichestein E, Gupta PK, Chadda KD, Lajam F. Sick sinus syndrome requiring permanent pacemaker implantation in a patient with mirror-image dextrocardia. Chest 1976;69:558–561. w5x Yeh ET, Bickford CL. Cardiovascular complications of cancer therapy: incidence, pathogenesis, diagnosis, and management. J Am Coll Cardiol 2009;53:2231–2247. w6x Lipshultz SE, Alvarez JA, Scully RE. Anthracycline associated cardiotoxicity in survivors of childhood cancer. Heart 2008;94:525–533.
