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ARTICLE CONTRIBUTORS

Pandula Athauda-arachchi

Nikolaos Tzemos

Douglas Elder

Prasad Guntur

Clinical Articles, Lead Article

Case report: Cardiac imaging conundrum resolved by clinical examination

The authors review the use of various cardiac imaging methods in their hospital, with the case report of a 77 year old man complaining of fatigue and dyspnoea following revascularisation and pacemaker implantation…

A 77 year old male presented to our emergency services complaining of progressive fatigue and dyspnoea. He could recall having surgical revascularisation for stable coronary artery disease and at a later date, implantation of a left-sided dual chamber pacemaker for ‘slow heart rate’. He had not been attending the outpatient clinic since then.

Chest radiographs (figure 1) unexpectedly revealed the presence of two right ventricular, one atrial and another (possibly located within the trunk of the main pulmonary artery) pacing lead electrodes. Transthoracic echocardiography and CT contrast enhanced pulmonary angiogram (figure 2a) also confirmed the presence of a retained pacemaker electrode lead within the lumen of the main pulmonary artery. Multiplane and 3D transoesophageal echocardiography (figure 2b) provided additional information of the anatomical relationship between the retained electrodes and surrounding structures and identified echogenic masses (likely thrombi) attached to the atrial side of one of the leads (click to see TOE video clip).

Antero-posterior (a) and lateral (b) chest radiographs showing the multitude of pacemaker electrodes located within the right atrial and ventricular chambers and also within the mid-mediastinum (arrows).

Figure 1. Antero-posterior (a) and lateral (b) chest radiographs showing the multitude of pacemaker electrodes located within the right atrial and ventricular chambers and also within the mid-mediastinum (arrows).

Figure 2-b. Three dimensional transesophageal echocardiography (mid-esophageal, 50o view), showing the retained pacemaker electrode (arrows) crossing the RVOT and pulmonary valve (PV) with its tip in contact with the lateral pulmonary artery (PA) wall. There is an echogenic mass (M) within the right atrium attached onto the functionless pacemaker lead. (RA-right atrium, LA-left atrium) (click to see TOE video clip).

Figure 2-b. Three dimensional transoesophageal echocardiography (mid-oesophageal, 50o view), showing the retained pacemaker electrode (arrows) crossing the RVOT and pulmonary valve (PV) with its tip in contact with the lateral pulmonary artery (PA) wall. There is an echogenic mass (M) within the right atrium attached onto the functionless pacemaker lead. (RA-right atrium, LA-left atrium) (click to see 3D TOE clips).

Figure 2-A. Contrast enhanced CT of the pulmonary arteries in axial view with the main pulmonary trunk at the level of its bifurcation. There is curvilinear blooming artefact (arrow) within the lumen of the vessel consistent with the presence of a retained pacing lead

Figure 2-a. Contrast enhanced CT of the pulmonary arteries in axial view with the main pulmonary trunk at the level of its bifurcation. There is curvilinear blooming artefact (arrow) within the lumen of the vessel consistent with the presence of a retained pacing lead

Figure 3-b. Antero-posterior chest radiograph (in the past), showing the original functionless pacemaker lead (arrow) with its tip secured within the right sub-pectoral area

Figure 3-b. Antero-posterior chest radiograph (in the past), showing the original functionless pacemaker lead (arrow) with its tip secured within the right sub-pectoral area

Figure 3-a. Patient’s upper trunk has a mid-line and left infra-pectoral (with slight skin elevation due to the presence of the generator) well healed scars. There is an additional flat curvilinear right infra-pectoral scar (arrow) consistent with previous pacemaker implantation

Figure 3-a. Patient’s upper trunk has a mid-line and left infra-pectoral (with slight skin elevation due to the presence of the generator) well healed scars. There is an additional flat curvilinear right infra-pectoral scar (arrow) consistent with previous pacemaker implantation

Careful physical examination of the patient’s upper chest revealed the presence of a well healed right infra-pectoral scar, thus hinting previous implantation of right-sided pacemaker. Following this finding, a detailed search of our hospital radiographic and medical records helped to solve the conundrum. The patient had a previous right-sided single chamber pacemaker implanted and the generator was later explanted due to malfunction. The retained functionless pacemaker electrode was then capped and secured to the sub-pectoral fascia and a dual chamber pacemaker was implanted contra-laterally. We could speculate that because of traction and following of the direction of blood flow, the retained part of the old pacing lead migrated progressively within the right heart circulatory apparatus thus reaching the main pulmonary artery through the pulmonary valve.

Migration of transvenous pacing electrodes to the pulmonary artery, although rare, is associated with significant morbidity due to concomitant high risk of pulmonary embolisation, infection, arrhythmia or displacement of the functioning pacing leads. It highlights the danger of a common practice of capping and leaving a non-functional pacing lead, in the belief that securing a lead is a safe option.

Conflicts of interest

None declared

Authors

Dr Pandula Athauda-arachchi
(pma29@cantab.net)

Dr Nikolaos Tzemos
(nikotzemos@yahoo.co.uk)

Dr Douglas Elder

Dr Prasad Guntur

Department of Cardiology and Radiology, Ninewells Hospital and Medical School Dundee, DD1 9SY, United Kingdom

<span style=”font-size: 20px; font-weight: bold;”><strong>Citation</strong></span>
George A, John J, Chattopadhyay S.  Dronedarone: a new therapeutic option for atrial fibrillation.  <em>BJC </em><em>Arrhythmia Watch</em> 2012;Issue 21 (Feb)

Citation

Athauda-arachchi P, Tzemos N, Elder D, Guntur P.  Cardiac imaging conundrum resolved by clinical examination.  BJC Arrhythmia Watch 2012;Issue 23 (Apr)

Published on: April 18, 2012

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