Thomas Avritt, MD
Resident
University of Kentucky
Lexington, Kentucky
Disclosure information not submitted.
David Bacon, MD
Assistant Professor
University of Kentucky College of Medicine
Lexington, Kentucky, United States
Disclosure information not submitted.
kevin hatton, MD, FCCM
Division Chief, Anesthesiology, Critical Care
University of Kentucky Albert B Chandler Hospital, United States
Disclosure information not submitted.
Shyanie Kumar, MD
Physician
University of Kentucky Chandler Medical Center, United States
Disclosure information not submitted.
Title: Malposition of Transvenous Pacing Wire in Hepatic Vein with Successful Capture
Case Report Body:
Introduction:
Transvenous (TV) pacing can be a life-saving procedure for symptomatic bradycardia. Ideally, the wire terminates in the apex of the right ventricle (RV). However, in emergent situations where real-time imaging is not available, placement is guided by electrical capture, and the terminal location is later identified with imaging. We present a case of a malpositioned but functioning TV pacing wire.
Description:
A 58 year-old man with a history of CAD s/p previous CABG presented to an outside hospital with an NSTEMI. Left heart catheterization demonstrated severe multivessel coronary disease, including 75-80% stenosis of the right coronary artery (RCA). Upon transfer to our facility, he required a dopamine infusion for symptomatic bradycardia with high degree heart block. The night following admission, the patient again developed symptomatic bradycardia, and epinephrine was added to the dopamine infusion with minimal improvement. With cardiology at bedside, a TV pacing wire was emergently placed (capture lost at 4 milliamps), and the patient was weaned expeditiously from all inotropes. A CXR was obtained, showing the tip of the wire in the left hepatic vein. Given that the pacemaker was capturing effectively and the patient's clinical status had improved dramatically, the wire was left in place with the plan to take the patient to the cardiac catheterization laboratory. Within hours, an RCA stent was placed, and his bradycardia resolved. The pacemaker was safely removed, and he was discharged two days later.
Discussion:
There are several reports of malpositioned but functioning TV pacing wires in various location. We are aware of no reports of a functioning TV pacemaker in the left hepatic vein. It is anatomically feasible for the wire to have reached that location, and the close proximity of the left hepatic vein to the RV makes conduction of an electrical impulse through the liver to the RV possible. Due to the dramatic improvement in patient symptoms, consistent capture with low milliamps, lack of any reported patient discomfort, and plan to take the patient to the cardiac catheterization lab soon after placement, the wire was left in place. Still, in such situations, we recommend pacing wire repositioning as soon as safely possible and devising a careful backup plan in the event that capture is lost.