Images in cardiology
Malposition of the pacemaker lead in the left ventricle
Pacemaker mal posicionado no ventrículo esquerdo
Eva M. Benito Martín
, Jose M. Rubín López, Cecilia Corros Vicente, Jesus M. De La Hera Galarza, Maria Martín Fernández
Corresponding author
Servicio de Cardiología, Hospital Central de Asturias, Oviedo, Spain
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(B) electrocardiogram following advanced cardiopulmonary resuscitation maneuvers; (C) angiograms showing acute thrombotic occlusion of the right coronary artery; (D) dominant left circumflex artery; and (E) final result of primary angioplasty of the non-dominant right coronary artery with recovery of flow in the two acute marginal branches to the right ventricle (arrows); (F) electrocardiogram with ST-segment elevation in leads V2R-V4R, confirming right ventricular ischemic injury.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juan Ruiz-García, Luis Pardillos-Ferrer, Raúl Moreno" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Juan" "apellidos" => "Ruiz-García" ] 1 => array:2 [ "nombre" => "Luis" "apellidos" => "Pardillos-Ferrer" ] 2 => array:2 [ "nombre" => "Raúl" "apellidos" => "Moreno" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001529?idApp=UINPBA00004E" "url" => "/21742049/0000003200000078/v1_201310270023/S2174204913001529/v1_201310270023/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2174204913001578" "issn" => "21742049" "doi" => "10.1016/j.repce.2013.10.003" "estado" => "S300" "fechaPublicacion" => "2013-07-01" "aid" => "291" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2013;32:629-32" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3400 "formatos" => array:3 [ "EPUB" => 145 "HTML" => 2652 "PDF" => 603 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Diffuse aneurysmal and obstructive coronary artery disease: A do-not-intervene patient" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "629" "paginaFinal" => "632" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Doença coronária aneurismática e obstrutiva difusa: um doente a não intervir" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3478 "Ancho" => 2333 "Tamanyo" => 734129 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abnormal coronary artery appearance in different techniques. A large aneurysm (arrowheads) is seen at the distal edge of the left main trunk (A1, B1, C1 and C2). The left anterior descending artery (LAD) presents several aneurysms (arrows) but also severe stenotic lesions (resembling a string of beads) with a poor distal bed (A1, B1 and C1). Note the absence of circumflex artery visualization. The ectatic right coronary artery (RCA) also presenting aneurysmal formations (arrows) and obstructive lesions (A2, B2 and C2). A: coronary angiograms of the LAD and RCA. B: curved planar reformation (CPR) in multislice computed tomography (MSCT) of the LAD and RCA. C: Three-dimensional MSCT reconstructions (volume-rendering technique). *: ascending aorta.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eulália Pereira, Bruno Melica, João Primo, João C. Mota, Nuno Ferreira, Gustavo P. Morais, Marta Ponte, Daniel Caeiro, Mónica Carvalho, Nuno Bettencourt, Luís Vouga, Vasco Gama" "autores" => array:12 [ 0 => array:2 [ "nombre" => "Eulália" "apellidos" => "Pereira" ] 1 => array:2 [ "nombre" => "Bruno" "apellidos" => "Melica" ] 2 => array:2 [ "nombre" => "João" "apellidos" => "Primo" ] 3 => array:2 [ "nombre" => "João C." "apellidos" => "Mota" ] 4 => array:2 [ "nombre" => "Nuno" "apellidos" => "Ferreira" ] 5 => array:2 [ "nombre" => "Gustavo" "apellidos" => "P. Morais" ] 6 => array:2 [ "nombre" => "Marta" "apellidos" => "Ponte" ] 7 => array:2 [ "nombre" => "Daniel" "apellidos" => "Caeiro" ] 8 => array:2 [ "nombre" => "Mónica" "apellidos" => "Carvalho" ] 9 => array:2 [ "nombre" => "Nuno" "apellidos" => "Bettencourt" ] 10 => array:2 [ "nombre" => "Luís" "apellidos" => "Vouga" ] 11 => array:2 [ "nombre" => "Vasco" "apellidos" => "Gama" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001578?idApp=UINPBA00004E" "url" => "/21742049/0000003200000078/v1_201310270023/S2174204913001578/v1_201310270023/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Images in cardiology</span>" "titulo" => "Malposition of the pacemaker lead in the left ventricle" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "633" "paginaFinal" => "635" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Eva M. Benito Martín, Jose M. Rubín López, Cecilia Corros Vicente, Jesus M. De La Hera Galarza, Maria Martín Fernández" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Eva M." "apellidos" => "Benito Martín" "email" => array:1 [ 0 => "evabenmar@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Jose M." "apellidos" => "Rubín López" ] 2 => array:2 [ "nombre" => "Cecilia" "apellidos" => "Corros Vicente" ] 3 => array:2 [ "nombre" => "Jesus M." "apellidos" => "De La Hera Galarza" ] 4 => array:2 [ "nombre" => "Maria" "apellidos" => "Martín Fernández" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cardiología, Hospital Central de Asturias, Oviedo, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "<span class="elsevierStyleItalic">Pacemaker</span> mal posicionado no ventrículo esquerdo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 556 "Ancho" => 1300 "Tamanyo" => 105810 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional transthoracic echocardiogram.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 70-year-old woman with a permanent VVI pacemaker implanted two years previously for advanced atrioventricular block came to our emergency department due to chest pain, dyspnea and palpitations for the past two hours. An electrocardiogram performed at that time showed atrial fibrillation at 140 bpm. After electrical cardioversion, the electrocardiogram during ventricular pacing showed a right bundle branch block pattern (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). No chest X-ray was performed at that time, but a previous one was investigated (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). A transthoracic echocardiogram (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>) suggested malposition of the pacemaker lead in the left ventricle with right atrial and ventricular dilatation, so a three-dimensional transesophageal echocardiogram (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>) was obtained that showed the pacemaker lead passing through a 2-cm interatrial communication and the mitral valve, and finally into the left ventricle.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Pacemaker lead malposition in the left ventricle is an uncommon complication but probably underdiagnosed due to its asymptomatic character in most cases.</p><p id="par0015" class="elsevierStylePara elsevierViewall">This complication should be considered when right bundle branch block is seen on a pacing electrocardiogram and the pacemaker lead has a posterior position on the lateral chest X-ray. A definitive diagnosis is obtained by echocardiography.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In asymptomatic patients, long-term anticoagulation therapy is preferred but in this case, with a symptomatic interatrial communication, we decided on surgical retraction of the lead and permanent closure of the septal defect.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical disclosures</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of human and animal subjects</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Confidentiality of data</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-12-04" "fechaAceptado" => "2013-01-19" "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1029 "Ancho" => 1792 "Tamanyo" => 214449 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 799 "Ancho" => 900 "Tamanyo" => 73354 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 622 "Ancho" => 1500 "Tamanyo" => 102238 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 556 "Ancho" => 1300 "Tamanyo" => 105810 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional transthoracic echocardiogram.</p>" ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003200000078/v1_201310270023/S2174204913001657/v1_201310270023/en/main.assets" "Apartado" => array:4 [ "identificador" => "9915" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Images in cardiology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003200000078/v1_201310270023/S2174204913001657/v1_201310270023/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001657?idApp=UINPBA00004E" ]
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