Vol 81, No 5 (2023)
Clinical vignette
Published online: 2023-03-29

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Leadless pacemaker implantation in a univentricular heart in a patient with a double-inlet left ventricle and L-transposition of the great arteries

Mateusz Tajstra1, Elżbieta Adamowicz-Czoch1, Anna Kurek1, Jolanta Nowak1, Jan Głowacki2, Karol Miszalski-Jamka2, Zbigniew Kalarus3, Mariusz Gąsior1, Oskar Kowalski3
Pubmed: 36999725
Kardiol Pol 2023;81(5):528-529.

Abstract

Not available

Clinical vignette

Leadless pacemaker implantation in a univentricular heart in a patient with a double-inlet left ventricle and L-transposition of the great arteries

Mateusz Tajstra1Elżbieta Adamowicz-Czoch1Anna Kurek1Jolanta Nowak1Jan Głowacki2Karol Miszalski-Jamka2Zbigniew Kalarus3Mariusz Gąsior1Oskar Kowalski3
13rd Department of Cardiology, Silesian Center for Heart Diseases, Medical University of Silesia, Zabrze, Poland
2Department of Diagnostic Imaging, Silesian Center for Heart Disease, Zabrze, Poland
3Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Center for Heart Diseases, Zabrze, Poland

Correspondence to:

Mateusz Tajstra, MD, PhD,

Silesian Center for Heart Diseases,

Szpitalna 2, 41–800 Zabrze, Poland,

phone: +48 32 3733674,

e-mail: mateusztajstra@wp.pl

Copyright by the Author(s), 2023

DOI: 10.33963/KP.a2023.0082

Received: January 19, 2023

Accepted: February 9, 2023

Early publication date: March 29, 2023

Leadless pacemakers (LP) should be viewed as an alternative to conventional transvenous systems to address typical limitations including venous route issues, lead-related complications, and infections [1, 2]. Additionally, they may be considered in complex patients [3]. Published data regarding LP implantation in adults with congenital heart disease (ACHD) are scarce [4, 5]. ACHD patients with complex cardiovascular anatomy are at high risk of conduction disturbances including complete heart block. This report describes a successful LP (Micra TM VR, Medtronic Inc., Dublin, Ireland) implantation in an ACHD patient with a univentricular heart.

A 42-year-old male with a single, double-inlet, significantly enlarged left ventricle (LV), with good global contractility, hypoplastic right ventricle (RV), ventricular septal defect, subvalvular pulmonary stenosis, aneurysmal dilated main pulmonary artery, and L-transposition of the great arteries (Figure 1AC, Supplementary material, Video S1), and permanent atrial fibrillation was admitted for symptomatic complete heart block. Several concerns were recorded regarding the higher risk of transvenous or epicardial system implantation, mainly including infective issues, potential lead-related thrombus formation and its embolization into the systemic circulation, and last but not least, lead-related mechanical complications (fracture, dislodgement), and the need for many re-do interventions. Using a multiple imaging modalities evaluation and following a careful discussion between the Heart Team and the patient, a decision was made to implant an LP into the LV.

Figure 1. A. Computed tomography scan Volume Rendering Technique. L-transposition of the great arteries the main pulmonary artery (blue arrow) and the aorta (yellow arrow) are in transposition. A significantly functionally enlarged single ventricle (red arrow). B. Cardiac magnetic resonance. Double-inlet left ventricle (LV) with two separate atrioventricular valves, enlarged left (LA) and right atrium (RA), rudimentary right ventricle, ventricular septal defect, and transposition of the great arteries. C. Transthoracic echocardiogram. Double-inlet LV with two separate atrioventricular valves, enlarged LA and RA. D. Transesophageal echocardiogram. Positioning of the leadless pacemaker. Delivery system (red arrows). E. Chest X-ray after the implantation; in anteroposterior view, the position of leadless pacemaker (red arrow). F. Electrocardiogram after leadless pacemaker implantation showing a successful ventricular-paced rhythm with underlying atrial fibrillation

The LP procedure was carried out under general anesthesia, based on fluoroscopy and transesophageal echocardiogram navigation. A 12 F vascular sheath was introduced after the left femoral vein puncture and upsized through the 18 F to a 27 F Micra delivery system. The system with a Micra LP was directed from the right atrium to the LV with an attempt to place it in the LV apex (Figure 1D, Supplementary material, Video S2). Most probably, due to unfavorable angulation between the enormous right atrium and very large LV, effective LP implantation was technically demanding and the device, after initial release, was dislocated several times (with no possibility to push the LP against the LV wall), or unacceptable electrical parameters were noted (pacing threshold above 3 V/0.4 ms). As a result, the entire LP system was removed, and the patient was checked and prepared once again. Additionally, the delivery sheath was manually reshaped to obtain larger curvature (Supplementary material, Video S3). Consequently, the LP system was successfully placed near the LV apex (Supplementary material, Video S4). Multiple stability “tug” tests and electrical parameters (R wave of 11.4 mV, threshold of 0.5 V@0.4 ms, and impedance of 640 ohms) were evaluated before ultimate LP system deployment (Supplementary material, Video S5, S6). The device was released and its position rechecked for the stability, and electrical parameters on the day following the implantation were measured (Figure 1EF). The patient was discharged two days later in good clinical condition.

We have shown that LP implantation, though challenging, is safe and feasible in a patient with a univentricular heart. It may be presumed that the number of ACHD patients with a high incidence of severe atrioventricular conduction disturbances secondary to disease progression and multiple interventions will grow. LP implantation seems to be a very attractive clinical option in this population.

Supplementary material

Supplementary material is available at https://journals.viamedica.pl/kardiologia_polska.

Article information

Conflict of interest: None declared.

Funding: None.

Open access: This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, which allows downloading and sharing articles with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially. For commercial use, please contact the journal office at kardiologiapolska@ptkardio.pl.

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Polish Heart Journal (Kardiologia Polska)