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precordial transition in V4&#44; rS in DI&#44; RsR&#8217; in V1&#8211;V2&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#41;&#59; and a posterior lead orientation on the lateral chest radiograph &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41;&#46; We suspected the lead to be in a branch of the coronary sinus&#46; The uncertainty prompted further investigation&#46; Transthoracic echocardiography &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A&#41; followed by transesophageal examination revealed the pacing lead entering the LV through the aortic valve and inserted in the mid part of the lateral wall&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Thoracic computed tomography &#40;CT&#41; angiography highlighted the entire trajectory&#59; it revealed the lead leaving the subclavian vein&#44; penetrating the aortic wall between the brachiocephalic trunk and the emergence of the left common carotid artery&#44; and continuing its way to the left ventricle through the ascending aorta and aortic valve &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B&#8211;D&#41;&#46; The ascending aortic aneurysm &#40;5&#46;8 cm&#215;5&#46;7 cm&#41;&#44; with calcified atherosclerotic plaques&#44; was confirmed without signs of dissection or hematoma&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient showed no clinical manifestation of this complication and refused any surgical intervention&#44; including lead removal&#46; She remained on heart failure medication and oral anticoagulation&#46; No clinical or echocardiographic worsening related to the lead&#39;s position occurred during 12 months of follow-up&#46; Chronic sensing and pacing parameters remained within normal ranges&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Inadvertent endocardial LV placement of a pacing lead by aortic perforation is both possible and easy to overlook if the electrocardiographic and radiologic signs are misinterpreted&#46; The interventional cardiologist must be aware of the situation as further unprotected interventional lead manipulation or extraction could result in serious mechanical complications&#46; An RBBB pattern of the paced rhythm may be encountered in both LV and right ventricular pacing&#46; In order to assess the lead&#39;s position&#44; Okmen et al&#46; proposed electrocardiographic criteria &#40;left axis deviation between &#8722;30&#176; and &#8722;90&#176;&#44; precordial transition in V3&#44; absence of S wave in DI and qR or RS pattern in V1&#41; that proved to be highly sensitive and specific for true right ventricular pacing&#59; not meeting these criteria&#44; as in our case&#44; strongly suggests a pacing site outside the right ventricle&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Aortic perforation by a pacing lead can be a life-threatening event&#59; it carries a high risk of systemic thromboembolism due to the LV endocardial lead position in the systemic circulation and&#44; in this case&#44; to atrial fibrillation&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;9</span></a> and mechanical complications &#40;aortic wall trauma resulting in massive hemorrhage&#44; or trauma to the lead&#44; aortic valve or coronary arteries&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;3</span></a> In our patient&#44; appropriate oral anticoagulation &#40;INR between 2 and 3&#41; prevented thromboembolic events&#44; while calcification and stiffness of the aortic wall possibly prevented aortic laceration and internal bleeding at the time of perforation&#46; The coronary arteries were spared as the lead entered the left ventricle directly without engaging the coronary ostia&#46; No trauma to the aortic valve or worsening of regurgitation was detected by echocardiography but these possible negative effects remain to be further assessed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In both previously published reports&#44; inadvertent placement of the pacing lead in the left ventricle after perforation of the aortic arch was symptomatic &#40;recurrent left laryngeal nerve irritation and lead thrombosis&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> and large hemothorax and myocardial infarction<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a>&#41;&#46; One of the patients had a persistent left superior vena cava with an absent brachiocephalic vein that might have facilitated the complication&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> The leads were removed by conventional surgery through a median sternotomy with direct surgical closure of the aorta&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> and percutaneously by concomitant endovascular stent grafting of the aorta&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> respectively&#46; In our patient the unusual position of normal anatomical structures facilitated this complication&#46; Venous blood detected when puncturing&#44; and the radiologic appearance of the aortic aneurysm&#44; created the impression of a normal trajectory of the guide wire and lead &#40;subclavian vein-superior vena cava-right heart&#41;&#44; masking the complication during the intervention&#46; At the time of the diagnosis&#44; percutaneous removal was considered to carry a significant risk of mechanical complications&#46; The recommended treatment for symptomatic malpositioned leads in the left ventricle consists of surgical removal&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7&#44;9</span></a> but as the patient was asymptomatic and refused any surgical intervention&#44; we had no choice but to leave the lead in place&#46; We chose lifelong oral anticoagulation because&#44; besides the indication for the patient&#39;s atrial fibrillation&#44; it has proved successful in asymptomatic patients with the lead inserted in the LV &#40;usually through an atrial septal defect&#41; and when lead removal was impossible&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;9</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            2 => "Arco a&#243;rtico"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Inadvertent endocardial placement of a pacing lead in the left ventricle through the aortic valve is a rare complication with an unknown incidence because of inadequate reporting&#46; Reported cases are usually the result of lead insertion via the subclavian artery&#46; A possible but very unusual situation is endocardial lead insertion in the left ventricle after aortic arch perforation&#46; We report the case of a 72-year-old woman in whom a screw-in pacing lead accidentally perforated the aortic arch and continued its way through the ascending aorta&#44; aortic valve and left ventricle&#44; after insertion through the left subclavian vein&#46; We describe how this complication was diagnosed&#44; the predisposing factors&#44; the risks it carries and the ways in which devastating consequences have so far been avoided&#44; as the patient refused any surgical intervention including lead removal&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A coloca&#231;&#227;o inadvertida de um el&#233;trodo de <span class="elsevierStyleItalic">pacing</span> ao n&#237;vel do endoc&#225;rdio do ventr&#237;culo esquerdo&#44; atrav&#233;s da v&#225;lvula a&#243;rtica&#44; &#233; uma complica&#231;&#227;o rara&#44; com uma incid&#234;ncia desconhecida por ser incorretamente relatada&#46; Os casos relatados s&#227;o&#44; geralmente&#44; o resultado da inser&#231;&#227;o do el&#233;trodo atrav&#233;s da art&#233;ria subcl&#225;via&#46; Uma situa&#231;&#227;o poss&#237;vel&#44; mas muito incomum&#44; &#233; a coloca&#231;&#227;o do el&#233;trodo ao n&#237;vel do endoc&#225;rdio do ventr&#237;culo esquerdo&#44; ap&#243;s a perfura&#231;&#227;o do arco a&#243;rtico&#46; Relatamos aqui o caso de uma doente com 72 anos&#44; em que el&#233;trodo do tipo de fixa&#231;&#227;o ativa perfurou acidentalmente o arco a&#243;rtico&#44; continuando o seu trajeto atrav&#233;s da aorta ascendente&#44; da v&#225;lvula a&#243;rtica e do ventr&#237;culo esquerdo&#44; ap&#243;s inser&#231;&#227;o pela veia subcl&#225;via esquerda&#46; Descrevemos a maneira como esta complica&#231;&#227;o foi diagnosticada&#44; os fatores predisponentes&#44; os riscos associados a essa complica&#231;&#227;o e as formas poss&#237;veis de evitar algumas consequ&#234;ncias devastadoras at&#233; hoje&#44; considerando que a doente recusou qualquer interven&#231;&#227;o cir&#250;rgica&#44; incluindo a extra&#231;&#227;o do el&#233;trodo&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Right bundle branch block pattern of the paced rhythm electrocardiogram&#59; &#40;B&#41; lateral chest radiograph showing posterior orientation of the pacing lead&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Transthoracic echocardiography&#44; apical 4-chamber view&#44; showing the pacing lead passing through the aortic valve to insert in the left ventricular lateral wall&#59; &#40;B&#41; thoracic computed tomography angiography &#40;CTA&#41;&#44; maximum intensity projection image&#44; showing the entire trajectory of the pacing lead through the aneurysmal ascending aorta&#44; aortic valve and left ventricle&#59; &#40;C&#41; volume-rendered thoracic CTA showing pacing lead perforating the atheromatous aortic arch&#59; &#40;D&#41; volume-rendered thoracic CTA showing perforation site between the left common carotid artery and the brachiocephalic trunk&#46;</p>"
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Case report
Endocardial left ventricular pacing after accidental aortic wall perforation
Pacing endocárdico do ventrículo esquerdo, após perfuração acidental da parede aórtica
Raluca Şoşdeana,
Corresponding author
sosdean.raluca@umft.ro

Corresponding author.
, Bogdan Enachea, Răzvan Ioan Macarieb, Sorin Pescariua
a Department of Cardiology, “Victor Babeş” University of Medicine and Pharmacy, Timişoara, Romania
b Cardiology Clinic, Institute of Cardiovascular Medicine, Timişoara, Romania
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Inadvertent placement of the pacing lead in the left ventricle &#40;LV&#41; through the aortic valve is a rare complication of artificial pacemaker implantation with an unknown incidence because of inadequate reporting&#46; Reported cases are usually the result of inadvertent subclavian artery puncture&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;5</span></a> Regarding insertion of the lead through the aorta after aortic wall perforation&#44; to the best of our knowledge there are only two cases reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6&#44;7</span></a> In both of them the lead was removed&#44; and there is no evidence in the literature about possible predisposing factors or the management of such cases when lead removal is unfeasible&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 72-year-old woman&#44; particularly short&#44; obese and displaying kyphosis&#44; with moderate aortic regurgitation&#44; severe mitral regurgitation&#44; and an ascending aortic aneurysm&#44; underwent implantation of a single-chamber pacemaker for severely symptomatic complete atrioventricular block and atrial fibrillation&#46; During the intervention&#44; because the cephalic vein was inaccessible&#44; the left subclavian vein was punctured &#40;with evidence of venous blood&#41; and a Biotronik Selox ST 60 screw-in pacing lead was placed in an endocavitary position using a 7 F introducer&#44; with good pacing and sensing thresholds &#40;0&#46;5 V and 8&#46;3 mV&#44; respectively&#41;&#46; The procedure&#44; performed by an experienced operator&#44; was uneventful&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">After the intervention&#44; two unusual findings were made&#58; a right bundle branch block &#40;RBBB&#41; pattern of the paced rhythm &#40;with electrical axis of &#8722;150&#176;&#44; precordial transition in V4&#44; rS in DI&#44; RsR&#8217; in V1&#8211;V2&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#41;&#59; and a posterior lead orientation on the lateral chest radiograph &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41;&#46; We suspected the lead to be in a branch of the coronary sinus&#46; The uncertainty prompted further investigation&#46; Transthoracic echocardiography &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A&#41; followed by transesophageal examination revealed the pacing lead entering the LV through the aortic valve and inserted in the mid part of the lateral wall&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Thoracic computed tomography &#40;CT&#41; angiography highlighted the entire trajectory&#59; it revealed the lead leaving the subclavian vein&#44; penetrating the aortic wall between the brachiocephalic trunk and the emergence of the left common carotid artery&#44; and continuing its way to the left ventricle through the ascending aorta and aortic valve &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B&#8211;D&#41;&#46; The ascending aortic aneurysm &#40;5&#46;8 cm&#215;5&#46;7 cm&#41;&#44; with calcified atherosclerotic plaques&#44; was confirmed without signs of dissection or hematoma&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient showed no clinical manifestation of this complication and refused any surgical intervention&#44; including lead removal&#46; She remained on heart failure medication and oral anticoagulation&#46; No clinical or echocardiographic worsening related to the lead&#39;s position occurred during 12 months of follow-up&#46; Chronic sensing and pacing parameters remained within normal ranges&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Inadvertent endocardial LV placement of a pacing lead by aortic perforation is both possible and easy to overlook if the electrocardiographic and radiologic signs are misinterpreted&#46; The interventional cardiologist must be aware of the situation as further unprotected interventional lead manipulation or extraction could result in serious mechanical complications&#46; An RBBB pattern of the paced rhythm may be encountered in both LV and right ventricular pacing&#46; In order to assess the lead&#39;s position&#44; Okmen et al&#46; proposed electrocardiographic criteria &#40;left axis deviation between &#8722;30&#176; and &#8722;90&#176;&#44; precordial transition in V3&#44; absence of S wave in DI and qR or RS pattern in V1&#41; that proved to be highly sensitive and specific for true right ventricular pacing&#59; not meeting these criteria&#44; as in our case&#44; strongly suggests a pacing site outside the right ventricle&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Aortic perforation by a pacing lead can be a life-threatening event&#59; it carries a high risk of systemic thromboembolism due to the LV endocardial lead position in the systemic circulation and&#44; in this case&#44; to atrial fibrillation&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;9</span></a> and mechanical complications &#40;aortic wall trauma resulting in massive hemorrhage&#44; or trauma to the lead&#44; aortic valve or coronary arteries&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;3</span></a> In our patient&#44; appropriate oral anticoagulation &#40;INR between 2 and 3&#41; prevented thromboembolic events&#44; while calcification and stiffness of the aortic wall possibly prevented aortic laceration and internal bleeding at the time of perforation&#46; The coronary arteries were spared as the lead entered the left ventricle directly without engaging the coronary ostia&#46; No trauma to the aortic valve or worsening of regurgitation was detected by echocardiography but these possible negative effects remain to be further assessed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In both previously published reports&#44; inadvertent placement of the pacing lead in the left ventricle after perforation of the aortic arch was symptomatic &#40;recurrent left laryngeal nerve irritation and lead thrombosis&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> and large hemothorax and myocardial infarction<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a>&#41;&#46; One of the patients had a persistent left superior vena cava with an absent brachiocephalic vein that might have facilitated the complication&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> The leads were removed by conventional surgery through a median sternotomy with direct surgical closure of the aorta&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> and percutaneously by concomitant endovascular stent grafting of the aorta&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> respectively&#46; In our patient the unusual position of normal anatomical structures facilitated this complication&#46; Venous blood detected when puncturing&#44; and the radiologic appearance of the aortic aneurysm&#44; created the impression of a normal trajectory of the guide wire and lead &#40;subclavian vein-superior vena cava-right heart&#41;&#44; masking the complication during the intervention&#46; At the time of the diagnosis&#44; percutaneous removal was considered to carry a significant risk of mechanical complications&#46; The recommended treatment for symptomatic malpositioned leads in the left ventricle consists of surgical removal&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7&#44;9</span></a> but as the patient was asymptomatic and refused any surgical intervention&#44; we had no choice but to leave the lead in place&#46; We chose lifelong oral anticoagulation because&#44; besides the indication for the patient&#39;s atrial fibrillation&#44; it has proved successful in asymptomatic patients with the lead inserted in the LV &#40;usually through an atrial septal defect&#41; and when lead removal was impossible&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;9</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Inadvertent endocardial placement of a pacing lead in the left ventricle through the aortic valve is a rare complication with an unknown incidence because of inadequate reporting&#46; Reported cases are usually the result of lead insertion via the subclavian artery&#46; A possible but very unusual situation is endocardial lead insertion in the left ventricle after aortic arch perforation&#46; We report the case of a 72-year-old woman in whom a screw-in pacing lead accidentally perforated the aortic arch and continued its way through the ascending aorta&#44; aortic valve and left ventricle&#44; after insertion through the left subclavian vein&#46; We describe how this complication was diagnosed&#44; the predisposing factors&#44; the risks it carries and the ways in which devastating consequences have so far been avoided&#44; as the patient refused any surgical intervention including lead removal&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A coloca&#231;&#227;o inadvertida de um el&#233;trodo de <span class="elsevierStyleItalic">pacing</span> ao n&#237;vel do endoc&#225;rdio do ventr&#237;culo esquerdo&#44; atrav&#233;s da v&#225;lvula a&#243;rtica&#44; &#233; uma complica&#231;&#227;o rara&#44; com uma incid&#234;ncia desconhecida por ser incorretamente relatada&#46; Os casos relatados s&#227;o&#44; geralmente&#44; o resultado da inser&#231;&#227;o do el&#233;trodo atrav&#233;s da art&#233;ria subcl&#225;via&#46; Uma situa&#231;&#227;o poss&#237;vel&#44; mas muito incomum&#44; &#233; a coloca&#231;&#227;o do el&#233;trodo ao n&#237;vel do endoc&#225;rdio do ventr&#237;culo esquerdo&#44; ap&#243;s a perfura&#231;&#227;o do arco a&#243;rtico&#46; Relatamos aqui o caso de uma doente com 72 anos&#44; em que el&#233;trodo do tipo de fixa&#231;&#227;o ativa perfurou acidentalmente o arco a&#243;rtico&#44; continuando o seu trajeto atrav&#233;s da aorta ascendente&#44; da v&#225;lvula a&#243;rtica e do ventr&#237;culo esquerdo&#44; ap&#243;s inser&#231;&#227;o pela veia subcl&#225;via esquerda&#46; Descrevemos a maneira como esta complica&#231;&#227;o foi diagnosticada&#44; os fatores predisponentes&#44; os riscos associados a essa complica&#231;&#227;o e as formas poss&#237;veis de evitar algumas consequ&#234;ncias devastadoras at&#233; hoje&#44; considerando que a doente recusou qualquer interven&#231;&#227;o cir&#250;rgica&#44; incluindo a extra&#231;&#227;o do el&#233;trodo&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Right bundle branch block pattern of the paced rhythm electrocardiogram&#59; &#40;B&#41; lateral chest radiograph showing posterior orientation of the pacing lead&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Transthoracic echocardiography&#44; apical 4-chamber view&#44; showing the pacing lead passing through the aortic valve to insert in the left ventricular lateral wall&#59; &#40;B&#41; thoracic computed tomography angiography &#40;CTA&#41;&#44; maximum intensity projection image&#44; showing the entire trajectory of the pacing lead through the aneurysmal ascending aorta&#44; aortic valve and left ventricle&#59; &#40;C&#41; volume-rendered thoracic CTA showing pacing lead perforating the atheromatous aortic arch&#59; &#40;D&#41; volume-rendered thoracic CTA showing perforation site between the left common carotid artery and the brachiocephalic trunk&#46;</p>"
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Article information
ISSN: 21742049
Original language: English
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Revista Portuguesa de Cardiologia (English edition)
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