Permanent Pacing of the Heart Via a Coronary Sinus Branch

Abstract

A Al-Khadra, S Al-Awami, A El-Hassan, Permanent Pacing of the Heart Via a Coronary Sinus Branch. 1998; 18(4): 347-348 Transvenous right ventricular endocardial pacing has become the routine method of cardiac pacing among most surgeons. Lead placement in the coronary sinus is sometimes encountered, but usually promptly recognized and corrected. Conversely, in the presence of a congenital venous anomaly, electrode placement in a cardiac vein may not be easily recognized, as it mimics right ventricular apical position.1 The course of a long-term pacing from a cardiac vein is not known. We report here a case of a persistent left superior vena cava (PLSVC) in which a pacing lead via the left subclavian vein was inadvertently placed in a tributary of the coronary sinus, with effective cardiac pacing for two years. Case ReportA 60-year-old Saudi man was admitted with a four-week history of dizziness. There was no history of palpitation or chest pain. He had been diagnosed with hypertension and bronchial asthma five years prior to presentation, and diabetes mellitus type II a year later. The patient was on enalapril and salbutamol inhaler. His diabetes mellitus was controlled by diet. He stopped taking the enalapril a month prior to his presentation after he linked it with the development of dizzy spells.On examination, the patient was conscious and alert. His blood pressure was 160/90 mm Hg, while the pulse was 80/min with occasional irregularity. Chest examination showed a barrel-shaped chest with coarse crepitations scattered all over. No ronchi were heard. The rest of the physical examination was normal.A Holter monitor showed several sinus pauses, the longest of which was 2.5 sec. Two short episodes of paroxysmal supraventricular tachycardia were also recorded. Blood urea nitrogen, creatinine and serum electrolytes, and blood sugar were normal. A corrected sinus node recovery time of 2040 msec was recorded (normal <525 msec) 2 after the insertion of a temporary pacemaker via the right femoral vein. The patient was taken to the operating room where, under local anesthesia, a transverse skin incision at the inferior border of the left clavicle was made and a pocket to host the pulse generator was created between the pectoral's major muscle and the pre-pectoral fascia. Through the same incision, the left subclavian vein was punctured, and using Seldinger's technique, a transvenous lead was introduced. An image intensifier was used to direct the pacing lead to the apex of the right ventricle. It was difficult to position the lead at the apex of the right ventricle, as the tip of the lead tended to deflect away from the tricuspid orifice. After repeated trials and after ensuring that the threshold for pacing (1 mv) and the ability of the pacemaker to sense were good, the lead was left in this functional, though not ideal position. Valsalva's maneuver did not displace the tip of the lead.Postoperative ECG showed a normally functioning pacemaker but a QRS (the principal deflection in an electrocardiogram) with RBBB (r...