Pectus Excavatum Deforming Right Heart Causing Difficult Right Ventricular Pacing
R Cooper, A Magrath, J Somauroo
Keywords
pectus excavatum, right ventricular compression, temporary pacing
Citation
R Cooper, A Magrath, J Somauroo. Pectus Excavatum Deforming Right Heart Causing Difficult Right Ventricular Pacing. The Internet Journal of Cardiology. 2008 Volume 6 Number 2.
Abstract
A 93-year-old female was admitted to our emergency medicine department with syncope. Her ECG showed AF with complete heart block. She was haemodynamically stable so was transferred to the coronary care unit. Her echocardiogram identified an abnormally shaped right ventricle due to external compression. Her condition deteriorated due to prolonged periods of asystole. External pacing paddles were applied whilst she was transferred to the pacing room. A single pacing wire was passed towards the right ventricle. The tricuspid valve was navigated easily, but with some difficulty the wire was eventually placed in the right ventricle with a threshold of 1.3 volts. A thoracic CT scan identified a congenital pectus excavatum deformity compressing the right ventricle (see image), obstructing the passage of the pacing wire. The patient was transferred for insertion of VVI pacemaker. This was also reported as being difficult requiring a ventricular screw-in lead at the apex.
Case Report
A 93-year-old female was admitted to our emergency medicine department with syncope. She had a history of ischaemic heart disease, but no known arrhythmia. Her ECG showed atrial fibrillation with AV dissociation and a wide complex ventricular escape rhythm with a rate of 50 bpm. She was haemodynamically stable so was transferred to the coronary care unit. Her peak troponin T reached 0.77. All electrolyte abnormalities and thyroid dysfunction were ruled out. Her chest x-ray showed pulmonary oedema. Her portable echocardiogram showed well preserved left ventricular function and identified an abnormally shaped right ventricle due to external compression. Her condition deteriorated due to prolonged periods of asystole up to 20 seconds. External pacing paddles were applied whilst she was transferred to the pacing room. The right internal jugular vein was cannulated under ultrasound guidance and a single pacing wire passed towards the right ventricle. The tricuspid valve was navigated easily, but some difficulty was experienced in securing the lead in place. The wire was eventually placed in the right ventricle with a threshold of 1.3 volts. The patient remained unstable throughout the procedure and external pacing was required intermittently. A thoracic CT scan identified a congenital pectus excavatum deformity compressing the right ventricle (see image), obstructing the passage of the pacing wire. The patient remained stable and was transferred for insertion of permanent VVI pacemaker. This was also reported as being a difficult procedure requiring a ventricular screw-in lead at the apex. She was well at follow up 4 months later.
Figure 1
RA: Right Atrium
RV: Right Ventricle
LA: Left atrium
LV: Left ventricle
St: Sternum
Ao: Aorta
TPW: Temporary Pacing Wire
MPA: Main Pulmonary Artery
Correspondence to
Dr Robert Cooper SHO Cardiology Liverpool Heart and Chest Hospital 1 Limewood Close Newton ,Chester Cheshire CH2 2HD UK robcooper@doctors.net.uk (0044) 7969565338 (0044) 1244 315279