Asian Cardiovasc Thorac Ann 2000;8:396-397
© 2000 Asia Publishing EXchange Pte Ltd
Right Ventricular Endocardial Pacing With Tricuspid Valve Replacement
Hitoshi Ogino, MD,
Masahiko Matsumoto, MD,
Tatsuya Yoshioka, MD,
Takaaki Sugita, MD,
Yuichi Ueda, MD,1
Department of Cardiovascular Surgery
Tenri Hospital
Nara, Japan
1 Department of Thoracic Surgery
Nagoya University, School of Medicine
Nagoya, Japan
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For reprint information contact: Hitoshi Ogino, MD Tel: 81 6 6833 5012 Fax: 81 6 6872 7486 email: hogino{at}hsp.ncvc.go.jp Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan.
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Abstract
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A novel technique for simultaneous tricuspid valve replacement and endocardial pacing is described. The technique was applied in a 67-year-old man who had previously undergone coronary artery bypass grafting and subsequent pericardiotomy via a left thoracotomy. He developed congestive heart failure due to tricuspid valve regurgitation as well as impaired left ventricular function with bradycardia. Endocardial pacing was successfully performed in conjunction with tricuspid valve replacement using a bioprosthesis via a right anterolateral thoracotomy.
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Introduction
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The combined procedures of tricuspid valve replacement (TVR) and endocardial pacing are considered undesirable. We describe a novel technique for right ventricular endo-cardial pacing in conjunction with TVR using a bio-prosthesis.
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Technique
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Surgery is carried out through a right anterolateral thoracotomy in the fourth intercostal space with cardio-pulmonary bypass established by axillary and femoral arterial cannulation, and with conventional bicaval drainage. With a beating heart and core cooling to 34°C, the right atrium is opened. Two screw-in endocardial pacing leads (Pacesetter, Sylmar, CA, USA) are implanted into the apex of the right ventricle. These leads are fixed using pledgetted mattress sutures of 4/0 polypropylene at different sites on the tricuspid ring.1 TVR is carried out in the standard manner using a 33-mm Carpentier-Edwards porcine bioprosthesis (Baxter Healthcare Corp., Irvine, CA, USA). The proximal tips of the pacing leads are pulled out through the closure line of the right atriotomy. They are picked up via a right thoracotomy and connected to the pacing generator set at a rate of 85 beats•min–1 and positioned in the subclavicular fossa (Figure 1
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Figure 1. Tricuspid valve replacement and right ventricular endocardial pacing. (A) Two screw-in endocardial pacing leads are implanted into the apex of the right ventricle and fixed at sites on the tricuspid ring. (B) Tricuspid valve replacement is carried out using a bioprosthesis. The proximal tips of the pacing leads are pulled out via the closure line of the right atriotomy, picked up via a right thoracotomy, and connected to the pacing generator positioned in the subclavicular fossa. TV = tricuspid valve, PM = pacemaker.
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Discussion
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The technique was devised for a 67-year-old man with an old myocardial infarction who had undergone coronary artery bypass grafting and subsequently developed con-strictive pericarditis. He had a pericardiotomy through a left anterolateral thoracotomy 8 years later but his heart failure worsened over the next 5 years. Cardiac cath-eterization revealed severe tricuspid regurgitation with moderate, secondary pulmonary hypertension due to impairment of left ventricular function. The mean right atrial pressure was 23 mm Hg, pulmonary artery pressure was 45/20 mm Hg, mean pulmonary capillary wedge pressure was 22 mm Hg, and left ventricular end-diastolic pressure was 24 mm Hg. There were signs of severe right heart failure: severe jugular vein distension with a bounding pulse, hepatomegaly, ascites, and varicose veins in both legs. His heart failure became uncontrollable despite intensive medical therapy with milrinone. Combined procedures of tricuspid valve surgery and right ventricular pacing were indicated. However, because of severe adhesions due to previous surgery, a repeat sternotomy was undesirable. Fortunately, tricuspid valve surgery involved only a right anterolateral thoracotomy, but post-pericardiotomy adhesion was predicted to make ventricular pacing difficult. Therefore, the endocardial pacing technique described above was employed.
The tricuspid valve showed poor coaptation of the 3 leaflets due to an unexpected congenital cleft between the anterior and posterior leaflets, and also because of secondary annular dilation as a result of long-standing pulmonary hypertension. The patient required TVR rather than annuloplasty because his tricuspid insufficiency was severe and accompanied by pulmonary hypertension. Completion of these procedures through a right antero-lateral thoracotomy took longer than usual because the operative field was restricted due to severe ventricular adhesion, and it took longer to find appropriate endocardial pacing sites. The patient was weaned smoothly from cardiopulmonary bypass (duration, 163 minutes) with a low dose of dopamine. He recovered well, with a decrease in body weight of 15 kg in the week after surgery, due to the elimination of edema caused by longstanding tricuspid regurgitation. Postoperative echocardiography did not reveal any perivalvular tricuspid regurgitation, particularly at the site of attachment of the pacemaker leads.
Lee2 reported successful coronary sinus pacing after TVR. However, this is less reliable than standard endocardial or epicardial pacing and the pacing threshold tends to increase more quickly.2 As an alternative, transvalvular implantation of an endocardial pacing lead in conjunction with TVR using a bioprosthesis has been reported.3 As this is likely to cause malfunction of the bioprosthesis, the technique described here was devised. Screw-in endocardial leads are preferable in this procedure to avoid floating of the leads because they should be fixed tightly to the tricuspid ring before TVR. If not, dislodgment of a lead tip could occur due to movement of the tricuspid ring during cardiac contraction.
A unique feature of this technique is that the implanted endocardial leads were pulled out through the closure line of the right atriotomy and connected to the pacing generator positioned in the subclavicular fossa. A similar technique has been reported.1 However, our patient required combined surgery for TVR and endocardial pacing, differing from the previous case where a pace-maker was implanted using an endocardial lead before TVR.1 This technique for right ventricular endocardial pacing and TVR led to the successful recovery of a critically ill patient.
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References
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Egawa Y, Yoshinari M, Monden Y, Kitagawa T, Kato I, Kurokami K. Preservation of endocardial lead during tricuspid valve replacement in a patient with a permanent pacemaker. Cardiac Pacing 1988;4:432–5.
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Lee ME. Special considerations in ventricular pacing in patients with tricuspid valve disease. Ann Thorac Surg 1983;36:89–92.[Abstract]
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Pernenkil R, Wright JS. Endocardial pacing through a prosthetic tricuspid valve. Pacing Clin Electrophysiol 1990;13:1365–6.[Medline]
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Abstract
Introduction
