An 84-year-old man with a history of arterial hypertension, ischemic heart disease, paroxysmal atrial fibrillation (without anticoagulant therapy), a stenotic syndrome, prostate enlargement — admitted due to escape junctional rhythm with a frequency of 35/min with left anterior fascicular block, confirmed on the electrocardiogram (Figure 1A) On admission, coronavirus disease 2019 (COVID-19) infection was detected using Abbott antigen test. The patient was isolated and qualified for a temporary venous stimulation. An endocavitary electrode was implanted from the access through the right subclavian vein under the control of the intracardiac. Correct VVI stimulation was recorded. A routine chest X-ray was performed (Figure 1B). Patient started getting uneasy and aggressive despite receiving midazolam. He removed the electrode along with the vascular sheath. Despite another attempt, the electrode could not be inserted into the right subclavain vein. Another radiograph was taken. It showed the sheath was strongly folded to electrodes (Figure 1C). During the attempt to remove the sheath, strong resistance was encountered. The cannula was removed by direct traction when the shoulder was abducted towards the head. Then, an endocavitary electrode was implanted through the right femoral vein. On the second day of stay, the stimulating system was implanted. In the performed computed tomography and X-ray imaging examinations of the chest without complications of the procedure (Figure 1D–E). The patient was transferred for further treatment to the COVID-19 hospital. Hemodynamically significant bradycardia necessitates implantation of the electrodes for temporary stimulation and COVID-19 creates severe difficulties in managing and securing the patient with temporary stimulation. Some authors present cases where pharmacotherapy is used to avoid temporary stimulation [1]. However, in this particular case due to the advanced, symptomatic bradycardia, pharmacotherapy was not attempted. In the presented case the reason for the difficulties in implanting the endocavitary electrode was the tightness between the clavicle and the first rib, which may appear as a thoracic outlet syndrome (TOS). It is a group of clinical symptoms caused by pressure on the vascular-nerve structures, passing through the upper thoracic opening. Classification of this syndrome is based on the pathophysiology of symptoms with subgroups consisting of neurogenic (nTOS), venous (vTOS), and arterial (aTOS) etiologies. The definition (TOS) was first used by R.M. Peet in 1956 [2]. The occurrence of the syndrome is 3–80/1000 [3]. A long asymptomatic period is observed in some patients [4]. The provocative physical exam maneuvers, helpful in suspecting this syndrome, were not performed on our patient due to the general condition. In this specific case, there was a possibility of functionally acquired, age-related cervical spine abnormalities, abnormal tension in the muscular apparatus, and incorrect position of the neck, which could have a direct impact on problems with accessing the right subclavian vein. For this reason, it was decided to implantation of a temporary pacing electrode from the femoral approach, which is a safe alternative [5]. The above description indicates that if TOS is suspected, accessing the vessels in the upper thoracic opening might be problematic and other vascular access should be considered.

Conflict of interest

The authors declare no conflict of interest.

Funding

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