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    • br Discussion The major finding in this case is that

    2019-05-15


    Discussion The major finding in this case is that implantation of an active-fixation atrial pacing lead in the right atrial appendage caused right coronary artery perforation, resulting in life-threatening tamponade. Myocardial perforation with or without cardiac tamponade has been reported as a relatively rare complication associated with the pacemaker implantation procedure [1–10]. It is also known that active-fixation atrial leads are associated with more frequent complications compared to passive-fixation atrial leads and have been reported to cause rare complications such as pneumothorax and aortic perforation [11–13]. To the best of our knowledge, our case is the first in which the implantation of an active-fixation atrial pacing lead caused right coronary artery perforation. The determination of the etiology of device implantation-related cardiac tamponade is often difficult. We checked the movement of the cardiac silhouette on cinefluoroscopy in a 30° left anterior oblique view in the electrophysiology laboratory at the end of the procedure and confirmed the absence of pericardial effusion and cardiac tamponade. A very small portion of the screw tip penetrated the atrial wall of the right atrial appendage in our case, but there was no bleeding from this site during open chest surgery. However, bleeding was observed from the right coronary artery, which was located on the opposite site of the right atrial appendage. These findings suggested that the screw tip of the atrial lead penetrated the atrial wall during or after the implantation and scored the right coronary artery due to the motion of the purchase Sunitinib Malate 3.5h after the procedure, resulting in life-threatening cardiac tamponade refractory to intensive treatment including pericardial drainage. Perforation of the right coronary artery is a possible novel mechanism of cardiac tamponade caused by an active-fixation atrial pacing lead. Because complications associated with active-fixation atrial leads are related to implantation sites, such as pericardial effusion in patients with the atrial lead implanted in the right atrial free wall and aortic perforation in patients with the implantation site of the mid to high atrial septum [13], the low atrial septum might be a suitable site for active-fixation atrial leads in patients without persistent fossa ovale because of the low associated complication rate [14]. The right coronary artery is partially covered by the right atrial appendage and Pang et al. reported the close proximity of the atrial lead tip to the right coronary artery when positioned in the medial right atrial appendage [15]. In addition to the atrial lead implantation site in the right atrial appendage, the motion of the right atrial appendage has to be taken into account because in this case, the right coronary artery was injured by the atrial lead tip approximately 10mm away at the appendage apex. The right atrial appendage might be a suitable implantation site only for passive-fixation atrial leads, but not for active-fixation atrial leads, because of the risk of screw penetration and sequential collateral organ damage.
    Conclusions
    Conflict of interest
    Introduction A coved-type elevation is a typical electrocardiogram (ECG) change associated with Brugada syndrome (BrS). In a recent study, Nademanee et al. demonstrated that the underlying electrophysiological mechanism of BrS is abnormally delayed depolarization over the anterior aspect of the right ventricular outflow tract epicardium [1]. The association between BrS and vasospasms has been reported in several cases, and a coved-type ST elevation is known to be a result of ischemia of the conus branch of the right coronary artery [2]. Here we present a rare case of coved-type ECG change in a patient with ischemic heart disease during an ischemic ventricular tachycardia (VT) ablation procedure.
    Case report A 63-year-old man demonstrated a transient coved-type ECG change during catheter ablation of ischemic VT (Fig. 1). The patient had a history of both anteroseptal and inferior myocardial infarctions following coronary artery bypass grafting: left internal thoracic artery–#7, right internal thoracic artery–#10, and gastroepiploic artery–#4 posterior descending branch. Echocardiography revealed hypokinesis of the left ventricle (LV) both in the anterior and inferior walls with a partial anterior aneurysm. The baseline ECG showed slight ST-elevation in the chest leads (Fig. 1), which may have been caused by an anterior aneurysm.